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The  Care  of  the  Insane 


AND 


Hospital  Management 


BY 

CHARLES   WHITNEY    PAGE,    M.D. 

Assistant  Physician  Hartford  Retreat,  Hartford,  Connecticut 
1871  to  1872  and  1873  to  1888 

Superintendent  Connecticut  Hospital  for  the  Insane,  Middletown 
1898  to  1901 

Superintendent  Danvers  State  Hospital,  Danvers,  Massachusetts 
1888  to  1898  and  1903  to  1910 

Member  of  The  American  Medico-Psychological  Association 

The  Boston  Society  of  Psychiatry  and  Neurology 

The  New  England  Psychiatric  Society 

The  Massachusetts  Medical  Society 


BOSTON 

W.   M.  LEONARD,  Publisher 
1912 


Copyright,  191 2, 

BY 

W.  M.  LEONARD 


Stanhope  iprcss 

F.    H.  GILSON   COMPANY 
BOSTON,  U.S.A. 


To 
CAROLINE   COLLINS   PAGE 

MY   WIFE 

WHOSE  DEEP  SYMPATHY  FOR  THE  INSANE 
AND  GRATEFUL  APPRECIATION  OF  ALL  MEAS- 
URES CALCULATED  TO  ALLEVIATE  THEIR 
SUFFERINGS  HAVE  CHEERED  AND  GREATLY 
AIDED  ME  IN  A  LIFE  WORK  OF  MANY  PER- 
PLEXITIES    AND     HEAVY    RESPONSIBILITIES 


CONTENTS. 

Page 

Introduction. — Non-mecliamcal  restraint  of  the  insane.  —  Con- 
ditions essential  to  its  success 9 

Hospital  Trustees.  —  Method  of  selection. — Representative 
ability  and  character  important.  —  Trustee  duties,  responsi- 
bilities and  opportunities 15 

Superintendent.  —  Necessary  qualifications  of  the  man.  —  Im- 
portance of  wise  discipline  and  high  ideals.  —  Social  and 
official  duties 33 

Assistant  Physicians.  —  Discrimination  in  selection  important. 

—  Promotions.  —  ObUgations  assumed.  —  Official  duties.  — 
Advantageous  facilities  for  professional  development 57 

Laboratory  —  Its  importance  and  prospects.  —  Superior  advan- 
tages in  hospitals  for  the  insane 73 

Management  of  Patients.  —  What  "  non-restraint"  stands  for. 
— Methods  of  treatment  should  vary  to  meet  needs  of  dif- 
ferent cases  and  classes.  —  Obviating  restraint  better  than 
condemning  it.  —  Patients'  visitors.  —  Congregate  dining 
room 79 

Attendants  and  Nurses.  —  Characteristics  of  many  candidates. 

—  Difficult  duties.  —  Prime  necessity  for  self-discipline.  — 
Intelligent  sympathy  the  keynote.  —  A  case  showing  how 
kindness,  tact  and  perseverance  win.  —  Moral  elevation 
result  of  humane  effort.  —  Coping  with  iasane  patients  devel- 
ops the  nurse's  mental  ability  and  moral  character.  —  The 
inducements  of  high  ideals  properly  presented 105 

Appendix.  —  Managing  a  case  without  restraint.  —  The  impor- 
tance of  the  card  index  in  hospitals , . , , , .     133 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/careofinsanehospOOpage 


INTRODUCTION. 

Insanity  is  the  most  grievous  malady  ever  inflicted 
upon  mankind.  Unable  to  observe  accurately  or  to 
reason  correctly,  the  insane  man's  narrow,  ego-centric 
world  quickly  alienates  him  from  his  normal  associations 
and  interrupts  habitual  lines  of  conduct.  The  resulting 
aimless,  erratic  or  hazardous  manifestations  bring  upon 
him  antagonism  and  too  frequently  cruel  abuse.  Thanks 
to  science  and  advancing  civilization,  his  treatment  in 
modern  times  has  been  radically  changed  for  the  better. 
But  of  those  familiar  with  hospital  conditions  as  they 
exist  to-day,  few,  if  any,  would  venture  to  assert  that 
the  custodial  management  of  the  so-called  violent  insane 
is  wholly  satisfactory,  or  that  the  highest  standards  of 
moral  and  scientific  treatment  have  been  universally 
adopted. 

Notwithstanding  it  is  now  more  than  a  century 
since  satisfactory  results  were  obtained  by  managing 
the  insane  without  restraining  their  actions  through  the 
use  of  mechanical  apparatus,  it  is  to  be  feared  that  a 
majority  of  those  medical  and  non-medical  individuals 
who  have  been  responsible  for  or  engaged  in  the  treat- 
ment and  care  of  the  insane  have  not  fully  comprehended 

9 


10  CARE  OF  THE  INSANE' 

just  what  the  *' non-restraint  "system  of  managing  the  in- 
sane comprises.  Pinel  in  France,  Tuke,  Hill  and  Conolly 
in  England,  were  the  pioneers  in  this  himiane  method. 
Dr.  Conolly,  superintendent  of  the  insane  asylum  at 
Hanwell,  England,  through  his  devotion  to  the  cause, 
his  speech  and  writings  on  this  subject,  and  his  con- 
spicuous success  without  restraint  in  a  large  institu- 
tion for  the  care  of  the  insane,  forced  the  question  of 
"non-restraint"  upon  public  attention.  He  not  only 
fostered  "non-restraint"  ideas  and  developed  the  sys- 
tem for  the  benefit  of  patients  under  his  immediate  care, 
but  he  utilized  his  experience  and  success  as  an  object 
lesson  to  other  superintendents  for  the  benefit  of  the 
insane  wherever  confined  and  for  all  time.  Conolly, 
having  thoroughly  mastered  the  many  details  and  prob- 
lems involved  in  conducting  a  large  public  institution 
for  the  insane  on  the  "non-restraint"  basis,  was  justi- 
fied in  expressing  the  following  sweeping  and  well- 
considered  convictions  upon  this  subject,  viz.:  "After 
five  years'  experience  with  the  non-restraint  system,  I 
have  no  hesitation  in  recording  my  opinion  that  with  a 
well-constituted  governing  body,  animated  by  philan- 
thropy, directed  by  intelligence  and  acting  by  means 
of  proper  ofiicers,  there  is  no  asylum  in  the  world  in 
which  all  mechanical  restraint  may  not  be  abolished, 
not  only  with  safety,  but  with  incalculable  advantage." 


CARE   OF  THE   INSANE  II 

While  a  few  prominent  hospital  superintendents  have, 
since  Conolly's  day,  openly  condemned  his  methods, 
scoffed  at  his  claims  or  questioned  his  judgment,  doubt- 
less a  majority  of  those  responsible  for  the  management 
of  the  insane  have  regarded  his  ideas  as  extreme,  and 
many  have  viewed  absolute  '' non-restraint"  as  imprac- 
ticable. In  explanation  of  this  opposition  and  indif- 
ference, it  may  be  considered  probable  that  those  who 
have  been  antagonistic  to  the  system  of  "non-restraint" 
failed  to  apprehend  Conolly's  viewpoint.  Doubtless 
many  hospital  officials  acting  upon  a  superficial  concep- 
tion of  Conolly's  practice  have  regarded  the  elimina- 
tion of  mechanical  appliances,  strait-jackets,  wristlets, 
bed  harnesses,  etc.,  as  the  object  sought;  whereas,  he 
used  the  term  "non-restraint"  to  characterize  a  com- 
prehensive non-coercive  method  of  dealing  with  the 
insane.  He  had  in  mind  a  broad,  complete  system  of 
hospital  management  so  saturated  with  the  spirit  of 
"non-restraint,"  and  so  actuated  by  kindness,  patience, 
consideration  and  tact,  that  the  insane  would  not  be 
provoked  into  acts  of  physical  resistance,  consequently 
situations  or  conditions  suggesting  the  necessity  for 
restraint  would  seldom  arise.  Those  who  have  under- 
stood his  theories  and  his  practice  so  imperfectly  as 
to  suppose  they  had  accomplished  the  ends  he  aimed 
at  when  they  avoided  the  application   of   mechanical 


12  CARE  OF  THE   INSANE 

devices  through  severe  discipline,  harsh,  intimidating 
treatment  of  excitable  and  obstinate  patients,  or  by  the 
use  of  chemical  agents,  have  naturally  enough  failed 
to  discover  any  value  or  merit  in  '^non-restraint.'* 
Other  worthy  hospital  administrators  have  no  doubt 
been  so  engrossed  in  the  study  of  scientific  questions 
pertaining  to  mental  disease  and  pathology  that  they 
have  simply  failed  to  give  sufficient  attention  to  the 
humane,  social  and  moral  elements  which  are  funda- 
mental considerations  of  the  true  *' non-restraint"  mo- 
tive. Did  the  successful  adoption  of  the  "non-restraint" 
principle  in  hospitals  for  the  insane  depend  simply  upon 
official  edicts  forbidding  the  employment  of  old-time 
mechanical  instruments  of  restraint,  unquestionably  hos- 
pital authorities  would  universally  prefer  the  more  hu- 
mane form  of  treatment. 

That  Conolly  understood  what  it  signifies  to  man- 
age a  hospital  for  the  insane  successfully  on  "non-re- 
straint" lines  is  shown  by  his  declaration  in  which  he 
specifies  four  conditions  that  are  essential  to  success. 
These  requisites  are,  first,  "a  well-constituted  govern- 
ing body";  second,  such  a  body  "animated  by  phil- 
anthropy"; third,  philanthropy  "directed  by  intelli- 
gence"; and,  fourth,  "proper  officers"  —  an  executive 
force  of  assistants  and  nurses  responsive  to  the  high- 
est hospital  ideals,  which  must  be  entertained  and  per- 


CARE  OF  THE  INSANE  13 

sistently  inculcated  by  the  superintendent.  When  we 
realize  that  thousands  of  inexperienced  men  and  women 
yeariy  join  the  nursing  staff  in  state  hospitals,  that 
young  medical  men  are  constantly  entering  such  insti- 
tutions to  assume  official  duties,  and  that  a  large  1.  r- 
ber  of  private  citizens  —  ladies  and  gentlemen  —  are 
annually  appointed  to  serve  on  visiting  committees  or 
supervisory  and  directing  boards  in  connection  with 
such  public  institutions,  we  can  appreciate  the  neces- 
sity for  a  comprehensive  statement  in  the  form  of 
a  manual  or  handbook  from  which  interested  persons 
can  obtain  a  working  knowledge  of  the  best  hospital 
methods  and  possibilities,  and  can  qualify  themselves 
to  analyze  hospital  conditions  as  they  find  them,  or 
trace  to  their  obscure  origin  or  cause  intruding  results 
which  may  demand  attention.  In  the  absence  of  such 
a  printed  guide,  these  official  recruits  are  unable  to 
adjust  themselves  correctly  to  hospital  duties  or  to 
early  satisfy  a  personal  desire  to  promote  as  fully  as 
possible  true  philanthropy  in  this  most  promising  and 
too  much  neglected  field. 

Having  had  thirty-five  years'  service  as  a  medical 
officer  in  hospitals  for  the  insane,  much  of  his  effort  in 
later  years  having  been  given  to  the  practical  elabora- 
tion of  methods  employed  by  Dr.  Conolly,  the  writer 
has  been  persuaded  that  his  experience  and  observa- 


14  CARE   OF   THE   INSANE 

tions,  concisely  stated,  may  be  of  service  to  those  who 
desire  a  fuller  knowledge  of  the  internal  workings  of 
institutions  where  ^^non-restraint"  is  the  practice.  He 
therefore  respectfully  submits,  to  whom  it  may  concern, 
his  established  convictions  regarding  the  management 
of  institutions  which  care  for  the  insane. 


"A  WELL-CONSTITUTED  GOVERNING  BODY.'' 

A  medical  superintendent  thoroughly  qualified  to  fill 
the  position  of  executive  head  of  an  institution  for  the 
insane,  and  ambitious  to  rank  with  advanced  men  in 
his  profession,  may,  if  he  attempts  to  manage  the  pa- 
tients under  his  charge  in  accordance  with  "non- 
restraint"  ideals,  have  his  good  intentions  frustrated 
by  conditions  beyond  his  control.  The  most  formi- 
dable obstacle  to  his  success  that  can  possibly  confront 
him,  especially  in  the  beginning,  is  a  badly  constituted 
governing  body,  unsympathetic  or  antagonistic  trustees, 
a  board  chiefly  interested  in  securing  the  objects  which 
political  interests  ^deem  important,  or  unwilling  to  as- 
sume responsibilities  for  those  purposes  which  appeal 
mainly  to  humane  sentiments.  If  the  members  of  a 
board  hold  positive  notions  favoring  the  employment 
of  mechanical  restraint,  the  superintendent  cannot  pru- 
dently disregard  their  well-known  conceptions  on  this 
important  matter,  and  he  may  discover  that  his  faculty 
for  stating  things  or  his  powers  of  persuasion  fail  to 
convince  them  that  "non-restraint"  is  feasible  or  worth 
the  special  efforts  necessary  to  manage  patients  without 
using  mechanical  instruments  for  restraint. 

IS 


1 6  CARE  OF  THE   INSANE 

When  Conolly  referred  to  ''a  well-constituted  gov- 
erning body"  as  something  essential  to  success  with 
*' non-restraint"  treatment  of  the  insane,  he  had  in 
mind,  no  doubt,  the  failure  of  his  immediate  predeces- 
sors, Drs.  Charlesworth  and  Hill.  They  were  medical 
superintendents  and  had  satisfied  themselves  that  Tuke's 
"non-restraint"  treatment  of  insane  patients  at  the 
York  Retreat  was  not  only  a  sane  but  a  safe  system, 
and  should  be  the  common  practice  in  all  hospitals  for 
the  insane.  Yet  in  their  own  hospital  wards  its  appli- 
cation in  detail  was  only  partially  successful  owing  to  the 
opposition  of  the  governing  boards  under  which  they 
held  office.  Because  injudicious  and  absurdly  opin- 
ionated persons  are  sometimes  found  on  boards  of 
trustees  and  may  unwisely  overrule  the  better  judg- 
ment of  a  superintendent,  the  proposal  to  aboHsh  such 
governing  bodies  cannot  be  seriously  considered,  al- 
though such  a  step  has  been  suggested  in  some  parts 
of  this  country.  A  superintendent  constantly  feels  the 
need  of  official  advice  and  should  be  thankful  when  a 
board  in  a  friendly  spirit  points  out  defective  or  faulty 
decision,  errors  liable  to  happen  even  to  the  best  men. 
Then,  under  a  democratic  form  of  government,  there 
seems  a  necessity  for  a  duly  appointed  board  to  control 
the  general  affairs  of  each  public  institution;  to  hold 
real  and  personal  property  for  the  state;    to  appoint 


CARE   OF  THE   INSANE  1 7 

the  executive  officers;  to  formulate  or  sanction  rules  of 
management;  to  supervise  the  entire  plant  and  repre- 
sent officially  and  legally  the  state's  interests  as  occasion 
may  require. 

The  scope  of  their  powers  and  the  peculiar  respon- 
sibilities which  trustees  must  assume  suggest  the  im- 
portance of  exercising  especial  care  in  their  selection. 
And  yet  positions  on  such  boards  are  generally  obtained 
through  the  favor  of  the  predominant  political  party,  or 
its  highest  state  representative.  Often  political  con- 
siderations decide  the  character  of  such  important 
boards.  And  boards  thus  chosen  are  virtually  respon- 
sible to  the  community  at  large  for  the  operations  of 
broad,  altruistic  schemes  based  upon  the  most  refined 
phases  of  pure  philanthropy.  Doubtless  institution 
trustees  as  a  rule  intend  to  discharge  their  responsible 
duties  honestly  and  exercise  a  fair  degree  of  intelligence 
in  doing  so.  But  there  are  exceptional  instances,  and 
it  is  beKeved  that  many  individual  trustees,  occasion- 
ally at  least,  entirely  misunderstand  the  legitimate 
field  for  their  activities.  This  is  especially  true  of 
those  appointees  who  receive  such  hospital  positions 
as  a  reward  for  pohtical  service. 

It  is  not  surprising  that  trustees  enter  upon  their 
institutional  duties  with  erroneous  conceptions  in  re- 
spect to  their  official  functions  and  privileges,  since  the 


1 8  ^  CARE  OF  THE  INSANE 

province  of  the  hospital  trustee  is  so  ill  defined  by 
statutes  that  personal  interpretation  or  inclination  may 
naturally  enough  measure  a  trustee's  conjecture  as  to 
his  authority  and  prerogative.  While  a  trustee  now 
and  then  may  make  mistakes  in  beginning  his  public 
service  with  misdirected  zeal,  the  great  majority  de- 
liberate too  long  before  taking  an  active  part  in  the 
hospital  work. 

Hospital  trustee  boards  are  open  to  criticism  chiefly 
through  the  neglect  of  their  members  to  study  the 
problems  really  involved  in  the  work  they  presume  to 
supervise.  This  common  indifference  to  duties  volun- 
tarily assumed,  or  carelessness  in  such  respects,  may  be 
charged  in  most  cases  to  the  fact  that  these  boards  — 
these  supervising  or  directing  units  —  are  each  com- 
posed of  several  members,  varying  in  number;  conse- 
quently individual  responsibility  is  so  divided  that  any 
one  member  may  easily  estimate  his  own  share  as  of 
little  account,  arguing  that  he  constitutes  but  a  frac- 
tional part  of  the  organization.  This  inactive,  ineffi- 
cient way  of  discharging  their  official  obligations  is 
especially  true  of  the  new  and  less  prominent  members  of 
a  board  where  one  or  two  of  longer  experience  unhesi- 
tatingly assume  to  possess  complete  knowledge  of  in- 
stitution affairs  and  a  mastery  of  the  situation.  Thus, 
through  the  modesty  and  tacit  consent  of  the  other 


CARE  OF  THE  INSANE  I9 

members,  practically  a  single  individual  on  the  board 
often  controls  the  policy  of  an  institution. 

With  a  purpose  to  obviate  the  faults  of  divided  re- 
sponsibiHty  and  a  hope  of  fancied  gain  through  sys- 
tematizing conditions  in  the  various  institutions  of  the 
state,  a  general  commission  with  one  supervising  mem- 
ber has  been  proposed  as  a  substitute  for  the  usual 
local  boards.  Considered  superficially,  this  method 
would  seem  to  insure  a  more  complete  and  careful 
oversight  and  a  keener  sense  of  official  responsibihty. 
But  under  such  an  arrangement  the  commissioner 
might  be  inclined  or  forced  to  devote  either  too  httle  or 
too  much  attention  to  any  one  hospital.  If  attached  to 
but  one  or  two,  he  could  scarcely  fail  to  trench  upon  the 
executive  field,  overshadowing  the  superintendent  and 
thus  dispossessing  him  of  incentive  and  pride  in  his 
official  duties.  If  in  control  of  a  group  of  institutions, 
his  attention  would  extend  over  such  a  wide  field  of 
activities  that  he  would  be  unable  to  follow  out  details 
and  be  obliged  to  depend  upon  the  several  superin- 
tendents for  information,  virtually  accepting  their  ob- 
servations and  adopting  their  suggestions,  or  he  would 
enforce  upon  all  institutions  a  common  system  of  man- 
agement that  would  operate  to  suppress  local  ambi- 
tions and  eHminate  hospital  individuahty.  Machine 
methods  and  standards  are  never  conducive  to  prog- 


20  CARE  OF  THE   INSANE 

ress  in  the  domain  of  science  or  philanthropy,  and 
when  applied  to  the  public  institutions  of  the  state  will 
possibly  foster  political  schemes. 

Reasons  may  be  adduced  why  the  suppHes  of  several 
pubHc  institutions  should  be  obtained  by  a  central 
commission,  but  economy  should  not  be  expected  as 
the  natural  result  of  thus  concentrating  official  pur- 
chases. In  his  report  to  the  State  Charities  Aid  Asso- 
ciation,^ Mr.  H.  C.  Wright  demonstrates  that  the  more 
complete  and  rigid  the  system  of  central  control  over 
purchases  in  state  institutions,  the  greater  the  discom- 
fiture of  local  officials,  and  where  the  cost  of  such  cen- 
tral control  is  included  in  the  cost  of  maintenance 
financial  results  the  opposite  of  economy  are  reached. 
His  conclusions  are  based  upon  a  thorough  study  of 
conditions  in  New  York  and  Iowa,  where  four  slightly 
varying  systems  of  central  purchasing  agencies  are  in 
operation. 

The  ideal  hospital  board  should  be  composed  of 
carefully  selected  men  residing  within  the  hospital  dis- 
trict, each  one  a  prominent  representative  of  some 
profession  or  business  interest.  The  best  judgment 
obtainable  in  the  hospital  locality  should  thus  be  at  the 
service  of  the  state,  as  it  can  be  obtained  gratis  if  the 

*  Report  on  Methods  of  Fiscal  Control  of  State  Institutions. 
Henry  C.  Wright.    New  York,  19 lo. 


CARE   OF   THE  INSANE  21 

appointing  powers  will  ignore  political  influence  and 
select  for  such  honorary  positions  only  citizens  of  estab- 
lished reputation  in  respect  to  ability,  judgment  and 
character.  The  expert  knowledge  collectively  possessed 
by  a  board  thus  constituted  would  safeguard  the  inter- 
ests of  the  state,  as  well  as  those  of  its  wards,  and  be 
gladly  welcomed  by  all  superintendents,  as  the  daily 
management  of  the  usual  state  hospital  calls  into  req- 
uisition special  knowledge  in  many  professional  and 
business  lines.  Then  the  whole  field  of  institutional 
activities  is  certain  to  be  examined  and  criticized  by  a 
properly  interested  public,  and  the  probabilities  are 
that  every  step  in  hospital  work  and  development  will 
be  examined  and  criticized  by  outside  judges,  each  ex- 
pert in  his  own  line  of  activities.  In  this  way,  sooner 
or  later,  whatever  is  accomplished  will  be  gauged 
according  to  the  highest  standards  in  each  particular 
department. 

The  laws  of  the  state,  their  import  and  appHcation 
to  altered  circumstances  and  new  conditions,  call  for 
frequent  interpretation.  Medical  questions  are  ever 
pressing  for  consideration  and  their  solution  calls  for 
scientific  knowledge  in  medicine,  surgery,  dietetics,  psy- 
chiatry, etc.  Engineering  problems  in  connection  with 
construction,  heating,  ventilation,  water  supply,  sewage 
disposal    constantly   appear.     Connected   with   many 


22  CARE   OF   THE   INSANE 

hospitals  is  a  farm  department  which  will  not  escape 
the  critical  attention  of  the  agricultural  public  unless 
it  is  conducted  upon  advanced  theories  regarding  stock 
raising,  milk  production,  crop  rotation,  truck  farming, 
etc.  With  such  burdensome  duties  always  on  hand 
to  test  the  common  sense  and  technical  knowledge  of 
hospital  trustees  and  superintendents,  the  importance  of 
securing  for  service  on  each  institution  board  a  promi- 
nent lawyer,  a  scientific  physician,  an  able  engineer  or 
contractor,  a  pubKc-spirited  business  man  experienced 
in  general  affairs,  a  practical  farmer,  or  similar  recog- 
nized leaders  in  other  business  pursuits,  would  seem  to 
be  sufficiently  obvious  to  create  a  strong,  compelling 
public  sentiment,  influencing,  if  not  controlling,  such 
appointments. 

The  addition  to  hospital  boards  of  one  or  more 
ladies  possessing  keen  perceptions,  broad  sympathies 
and  balanced  judgment  insures  a  more  careful  consid- 
eration of  the  social  aspects  of  institutional  life  and 
service,  much  of  which  might  otherwise  escape  official 
attention. 

By  virtue  of  their  ofhce,  hospital  trustees  must  expect 
to  carry  heavy  responsibilities,  and  they  should  live  up 
to  the  requirements  of  the  position  faithfully  and  cheer- 
fully. They  must  arbitrate  the  often  conflicting  inter- 
ests of  the  public,  the  executive  officers  and  the  state 


CARE  OF  THE  INSANE  23 

wards.  Therefore,  they  should  weigh  well  their  deci- 
sions, which  may  produce  some  unforeseen  results.  It 
is  their  duty  to  determine  the  practical  boundaries  of 
public  disbursements  and  to  adjust  the  economical 
expenditure  of  state  funds.  They  must  discriminate 
between  legitimate  demands  and  selfish  desires.  They 
need  to  devote  much  time  and  careful  attention  to  the 
details  of  hospital  business  before  vouching  for  outlays 
and  receipts.  They  should  endeavor  to  secure  for  the 
patients  those  attentions  and  measures  which  will  be 
most  conducive  to  their  recovery,  physical  comfort  and 
peace  of  mind.  In  this  work  theyj  must  have  their 
feelings  enlisted  and  their  sympathies  taxed  without 
sacrificing  their  sense  of  proportion.  Personal  inclina- 
tions must  at  all  times  be  held  subservient  to  public 
expediency. 

If  a  well-ordered,  smoothly  conducted,  successful 
hospital  is  the  ambition  of  a  trustee  board,  it  must 
secure  an  able  executive  head  and  endow  him  with 
well-nigh  autocratic  powers,  although  the  board  would 
be  blame-worthy  if  it  failed  to  keep  informed  as  to 
the  guiding  principles  enforced,  the  general  results  of 
their  application  and  all  important  hospital  episodes. 
Different  boards  will  obtain  the  facts  pertaining  to 
such  matters  through  various  methods;  the  manner 
of  acquiring  this  information  is  largely  determined  by 


24  CARE  OF  THE  INSANE 

habit,  hospital  tradition,  the  personality  of  the  board 
members  and  the  superintendent.  Often  the  most 
active  member  of  the  board,  usually  the  president, 
entertains  a  lively  interest  in  hospital  work  and  being 
sufficiently  free  as  regards  private  business,  will  de- 
vote all  the  time  necessary  to  his  official  duties.  Thus 
he  acquires  intimate  personal  acquaintance  with  the 
superintendent  and  the  hospital  staff  and  supervises 
in  general  the  actual  workings  of  the  hospital  regime. 
Naturally  he  reports  to  his  colleagues  a  summary  of 
what  transpires  within  his  cognizance,  which  practi- 
cally covers  the  daily  round  of  hospital  activities. 
When  such  a  representative  trustee  is  diHgent  enough 
to  include  the  whole  field  of  hospital  operations,  is 
sufficiently  well  informed  and  well  balanced  to  correctly 
interpret  what  falls  under  his  observations,  and  is 
actuated  by  a  high  sense  of  honor  and  desires  to 
promote  both  individual  welfare  and  public  weal,  his 
associates  show  wisdom  in  following  his  initiative. 
But  a  board  that  blindly  or  willingly  supports  a  self- 
assertive  member  who  accepts  as  authentic  floating 
gossip  and  rumors  from  disgruntled  employees  and  se- 
cret agents,  allows  carelessness  or  prejudice  more  force 
than  is  consistent  with  reason. 

The  more  common  and  the  better  way,  by  which  a 
board  can  keep  in  practical  touch  with  the  internal 


CARE   OF  THE  INSANE  25 

management  of  the  institution  it  represents,  consists 
in  dividing  hospital  operations  into  departments  and 
appointing  from  its  membership  special  committees  to 
oversee,  investigate  as  necessary,  and  report  upon  each 
section.  By  the  interchange  of  information  thus  in- 
telligently obtained  and  by  free  discussions,  the  entire 
board  can  keep  reasonably  well  informed  upon  all  essen- 
tial details  of  routine  and  even  exceptional  occurrences. 
It  is  also  good  policy  for  trustees  to  visit,  unattended, 
all  parts  of  an  institution.  But  in  so  doing  it  should  be 
remembered,  especially  when  making  infrequent  trips, 
that  the  underlying  motives  and  the  interest  displayed 
may  be  the  subject  of  surmises  on  the  part  oi  many  in 
whose  interest  such  tours  are  planned. 

A  trustee  should  at  all  times  beware  of  flattery,  open 
or  veiled,  from  patients  or  subordinates.  If  he  enters 
into  familiar  relations  with  them,  some  will  take  ad- 
vantage of  even  sKght  opportunity  to  ingratiate  them- 
selves, and,  if  possible,  injure  the  standing  of  others. 
Victims  of  unwarranted  suspicions  or  pure  delusions 
will  often  endeavor  to  establish  such  a  S3anpathetic 
understanding  with  a  trustee  that  they  may  transplant 
into  the  official  mind  their  own  prejudiced  opinions 
and  warped  judgment.  With  the  kindest  intentions, 
an  incautious  trustee  may  accidentally  encourage  the 
foolishness  of  some  well-meaning  person,  who,  unable 


26  CARE  OF  THE  INSANE 

to  comprehend  more  than  one-half  the  truth  or  one 
side  of  an  issue,  is  honestly  mistaken,  and  therefore  the 
more  insistent  upon  securing  absurd  official  action. 
Not  infrequently  malicious  falsehoods  will  be  narrated 
with  such  assurance  and  circumstantiality  that  imless 
the  occasional  ward  visitor  is  exceptionally  discreet  and 
diplomatic  in  his  comments  he  may  feel  some  degree  of 
humiUation  when  the  facts  and  the  actual  situation 
are  finally  forced  upon  his  understanding.  Whether 
investigating  for  a  special  purpose  or  acting  upon  indi- 
vidual responsibility,  a  trustee  should  never  decline  to 
hear  a  complaint.  Yet  ordinary  prudence  should  lead 
him  to  suspend  judgment  and  to  insist  that  every  charge 
of  neglect  or  misconduct  be  reduced  to  writing  and  be 
properly  signed  by  the  author  of  the  complaint. .'  In 
all  institutions  rumors,  especially  those  interesting  or 
startling,  circulate  with  surprising  rapidity  among  both 
inmates  and  employees,  therefore  trustees  should  con- 
stantly guard  their  speech  lest  they  may  thoughtlessly 
answer  or  comment  in  terms  which  patients  can  quote 
to  the  injury  of  others,  especially  to  the  subordinate 
ofi&cials.  And  yet  trustees  should  give  the  hospital 
population  ample  opportunity  to  voice  their  response 
to  the  discipline  enforced  —  their  dissatisfactions  and 
their  alleged  grievances.  Then  the  whole  mass  of  infor- 
mation and  misinformation  —  truth  and  fabrication  — 


CARE   OF   THE   INSANE  27 

should  be  submitted  to  the  superintendent  to  be  sifted 
and  explained  as  fully  as  possible.  In  no  other  way 
can  trustees  obtain  a  comprehensive  knowledge  of  the 
conditions  with  which  a  superintendent  has  to  contend 
and  thoroughly  qualify  themselves  for  intelligent  con- 
ferences and  helpful  suggestions.  Besides,  they  may 
through  such  thorough  canvassing  of  patients'  wards 
learn  things  of  weighty  or  serious  import  which  had 
not  come  to  the  superintendent's  knowledge,  since  it  is 
not  imusual  for  patients  to  persistently  withhold  from 
him  material  facts  and  helpful  intimations  which  they 
will  voluntarily  report  to  trustees  upon  .the  first  op- 
portunity. Trustees  should  not  be  surprised  when  a 
superintendent  confesses  inabihty,  without  personal  in- 
vestigation, to  controvert  some  plausible  charge  or  un- 
ravel some  amazing  story  communicated  by  a  patient. 
The  patient  may  have  cunningly  omitted  essential  de- 
tails by  which  his  peculiar  view  of  things  could  be 
easily  recognized.  To  ascertain  from  some  patients, 
representing  certain  forms  of  mental  disorder,  the  key 
which  will  decipher  their  garbled  or  counterfeit  state- 
ments requires  the  skill  which  comes  only  from  long 
experience  with  the  insane.  Then,  a  superintendent  can- 
not be  onmipresent,  and  cannot,  because  of  the  limited 
time  at  his  command,  keep  intimately  informed  of  all 
that  transpires  within  his  jurisdiction.    However  vigi- 


28  CARE  OF  THE   INSANE 

lant  himself,  he  must  trust  his  staff  assistants  with 
considerable  independent  authority  and  depend  upon 
their  honor  and  judgment  for  the  variety  and  minute- 
ness of  their  detailed  reports.  Unfortunately  ready  ex- 
planations from  executive  officers,  who  may  have  been 
suddenly  called  upon  to  correct  ugly  rumors,  or  clear 
up  incriminating  statements,  should  not  be  accepted 
by  trustees  as  satisfactory  and  final  imder  all  circum- 
stances. Especially  is  caution  in  this  respect  neces- 
sary when  by  the  proffered  answer  the  veracity  of  some 
other  person  is  impeached  or  when  the  trustees  burden 
themselves  with  serious  and  unnecessary  responsibility 
through  overconfidence  in  a  subordinate.  Cirami- 
stances  can  be  imagined  under  which  it  would  be  ad- 
visable for  them  to  assume  that  a  superintendent  even, 
when  interrogated  closely,  might  offer  misleading  an- 
swers or  fictitious  excuses,  designing  thereby  to  pre- 
serve false  pride  or  conceal  inexcusable  ignorance  and 
personal  neglect  of  duty.  Of  course  this  is  a  mere 
possibiHty,  but  that  trustees  will  occasionally  differ 
with  a  superintendent  is  a  probability.  Opinions  may 
honestly  differ  as  opposite  convictions  upon  many 
questions  in  dispute  logically  follow  observations  made 
from  different  viewpoints.  Each  party  to  a  contro- 
versy should  therefore  in  simple  justice  make  certain 
his  judgment  does  not  rest  upon  a  narrow,  prejudiced 


CARE  OF  THE  INSANE  29 

basis.  Then,  it  is  well  to  bear  in  mind  that  the  spirit 
engendered  in  most  quarrels,  rather  than  the  facts  in- 
volved, perpetuates  uncompromising  conflicts  of  opinion. 
In  any  case  of  serious  clashing,  however  originating, 
the  board  has  the  major  share  of  responsibility,  as  it 
holds  the  vantage  by  virtue  of  its  legal  authority  and 
official  rank.  It  can  therefore  determine  how  a  solu- 
tion of  the  difficulties  shall  be  effected.  It  can  act 
summarily  and  defy  consequences,  yet  it  had  best  be 
conciliatory  and  first  exhaust  more  gentle  methods. 
Without  sacrificing  authority  or  dignity,  it  can  in  a 
friendly  spirit  dispassionately  review  with  the  superin- 
tendent the  points  at  issue  and  their  development.  If 
unsuccessful  in  reestabhshing  working  relations  with 
him,  a  board  will  by  resorting  to  benignant  treatment 
secure  credit  for  a  moral  victory  and  merit  the  support 
of  public  opinion.  When  trustees  cease  to  respect  a 
superintendent  their  official  relations  should  terminate 
for  the  good  of  the  cause,  which  cause  may  be  regarded 
as  a  grand  commission  for  unselfish  devotion  to  afflicted 
fellow  men. 

Eleemosynary  institutions  are  monuments  indicat- 
ing the  degree  and  strength  of  philanthropic  sentiments 
in  a  community  —  not  memorials  dedicated  to  past 
achievements,  but  energetic  centers  where  compassion 
for   misfortune   and   suffering   is   practically   demon- 


30  CARE  OF  THE   INSANE 

strated  through  the  agency  of  scientific  skill,  deeds  of 
mercy  and  the  arts  of  genuine  sympathy.  Hospital 
trustees  should  cherish  the  signal  honor  which  is  con- 
ferred upon  them  through  their  official  position,  and 
not  only  plan  and  vote  in  accordance  therewith,  but 
endeavor  to  impress  their  subordinates,  by  example  and 
precept,  with  a  constant  sense  of  deep  obligation  to  the 
helpless  patients  —  God's  unfortunate  children  in  a  spe- 
cial sense  —  for  whose  sole  benefit  such  benevolent  in- 
stitutions are  founded  and  maintained. 

So  far  as  possible,  trustees  should  agree  upon  all 
important  questions  of  hospital  management.  Dissen- 
sions in  a  board,  if  serious  and  prolonged,  can  scarcely 
fail  to  reduce  the  efficiency  of  the  hospital.  As  a  conse- 
quence of  board  friction  executive  officers  will  imbibe 
the  virus  of  uncertainty  and  may  gravitate  into  oppos- 
ing cliques,  while  employees  will  presume  upon  relaxed 
discipline  and  the  baneful  results  will  have  to  be  endured 
by  the  innocent  patients.  When  trustees  view  their 
official  duties  in  the  light  of  a  solemn  trust  for  the 
uplift  of  afflicted  humanity,  there  would  seem  to  be 
little  opportunity  for  personal  differences  concerning 
the  means  to  be  employed.  Experience  with  a  model 
board  in  this  respect  has  demonstrated  the  possibiHty 
of  practical  harmony  in  hospital  work.  Under  wise 
leadership,  minority  objections  to  any  proposition  were 


CARE  OF  THE  INSANE  31 

treated  with  entire  respect,  and  final  action  deferred 
while  each  member  endeavored  to  reexamine  his  con- 
victions from  the  viewpoint  advanced  by  others.  That 
self-respect  which  accords  such  marked  consideration 
for  the  opinions  of  an  associate  has  an  inherent  power 
that  will  force  a  spirit  of  humility  and  a  burden  of 
self-conviction  upon  any  manly  opponent  if  he  is  not 
certain  of  his  position,  and  insure  the  ultimate  adop- 
tion of  his  views  by  the  majority  if  he  is  absolutely 
right. 

When  a  trustee  board  adopts  a  standard  of  high 
ideals  and  secures  a  competent,  ambitious  superinten- 
dent, excellent  results  should  follow.  But  a  board 
must  utilize  its  opportunities  with  skill  and  use  its 
power  with  masterful  restraint,  if  it  would  fully  dis- 
charge its  special  obHgations  to  the  pubHc  as  well  as  to 
the  state  wards.  Having  established  with  the  super- 
intendent a  mutual  understanding  concerning  the  set- 
tled poHcy  and  the  general  plans  to  be  pursued,  the 
board;  should  delegate  to  him  adequate  authority  to 
enforce  his  orders  and  maintain  a  position  of  dignity. 
Only  under  exceptional  circumstances  should  a  board, 
acting  as  a  committee  of  the  whole  or  through  its  pre- 
siding officer,  assume  direction  in  executive  affairs. 
The  superintendent  must  be  the  acknowledged  com- 
mander, free  to  select  his  working  force,  to  formulate 


32  CARE   OF  THE   INSANE 

details  of  operation,  and  to  establish  his  own  system  of 
discipline. 

Finally,  after  their  hospital  has  been  put  in  working 
order,  the  board  can  render  the  most  effective  service 
by  occupying  the  position  of  rear  guard.  As  trustee 
officials  they  cannot  escape  the  position  of  buffer  be- 
tween the  hospital  management  and  the  general  public. 
Therefore  it  becomes  their  duty,  as  well  as  their  privi- 
lege, to  aid  the  formation  and  growth  of  a  public  senti- 
ment favorable  to  the  hospital.  This  they  can  do  by 
cheerfully  answering  all  pertinent  questions;  by  cor- 
recting unfounded  rumors;  by  disarming  hostile  criti- 
cism, and  by  freely  and  fairly  discussing  with  any 
interested  person  the  quaHfications,  the  aims  and  the 
ambitions  of  the  resident  officials. 


SUPERINTENDENTS. 

The  responsibility  of  hospital  trustees  assumes  its 
maximum  proportions  when  the  board  essays  to  select 
a  medical  superintendent,  as  successful  hospital  admin- 
istration depends  almost  wholly  upon  the  individual 
chosen  for  that  office.  The  attainments  and  character 
of  the  chief  executive,  his  medical  qualifications,  his 
business  instincts,  his  executive  capacity  and  his  per- 
sonaHty  have  each  an  important  value  in  fitting  him 
for  the  varied  duties  inseparable  from  the  position. 
Should  the  candidate  possess  acknowledged,  even  con- 
spicuous, ability  in  any  particular  field,  medical,  com- 
mercial or  sociological,  such  preeminence  does  not  sig- 
nify that  he  possesses  the  ability  to  organize  hospital 
work  successfully  and  maintain  proper  discipHne.  It 
is  a  much  safer  policy  to  fill  the  position,  with  its  various 
lines  of  duty,  by  appointing  an  evenly  balanced,  ^^all- 
roimd'^  man,  who  in  addition  to  the  requisite  medical 
knowledge  and  business  capability  is  blessed  with 
abundant  common  sense,  quick  perception,  a  ready  judg- 
ment and  a  passion  for  justice;  for  not  only  must  a 
superintendent  see  that  the  patients  receive  the  best 

33 


34  CARE  OF  THE  INSANE 

medical  care,  that  hospital  funds  are  prudently  han- 
dled, that  employees  conduct  themselves  properly,  but 
in  him  should  reside  these  finer  qualities  of  mind  and 
heart, —  patience,  sympathy,  courage,  enthusiasm,  etc., 
—  since  such  attributes  of  higher  manhood  must  char- 
acterize his  administration  in  order  that  his  life  and 
official  influence  may  tone  and  energize  the  interrela- 
tions of  the  whole  hospital  community. 

It  has  been  the  custom  to  a  considerable  extent,  in 
hospitals  for  the  insane,  to  promote  assistant  physi- 
cians whenever  the  position  of  superintendent  became 
vacant.  But  the  exceptions  to  this  rule  have  been 
frequent,  and  the  medical  chief  has  sometimes  been 
selected  from  the  class  of  general  practitioners  of  medi- 
cine. In  former  times,  when  there  was  an  actual  dearth 
of  specially  instructed,  promising  candidates  for  such 
positions,  selection  from  the  non-specialist  field  was 
almost  a  necessity,  and,  as  a  matter  of  fact,  some  medi- 
cal superintendents  who  entered  upon  their  hospital 
duties  without  previous  special  experience  in  the  treat- 
ment or  management  of  the  insane  made  a  good  record. 
In  recent  years,  however,  the  number  of  ambitious 
young  medical  men  possessing  hospital  experience  and 
a  knowledge  of  psychiatry  has  largely  increased,  owing 
to  the  fact  that  the  number  and  size  of  hospitals  for 
the  insane  have  rapidly  increased,  necessitating  a  much 


CARE  OF  THE  INSANE  35 

larger  staff  of  assistant  physicians  and  graduate  "in- 
ternes" to  perform  the  increased  professional  labors 
which  new  views  of  this  work  and  improved  methods 
demand.  Therefore,  when  a  reasonable  degree  of  dis- 
crimination is  exercised  in  filling  the  minor  staff  posi- 
tions, the  promotion  of  assistants  to  fill  higher  vacan- 
cies would  seem  logical  and  fitting,  especially  in  those 
institutions  where  the  established  hnes  of  management 
are- satisfactory  to  the  trustees  and  all  supervising  offi- 
cials. Certainly  an  assistant  physician,  who  after  years 
of  faithful,  continuous  service  in  the  hospital  has  be- 
come familiar  with  the  routine  work  and  the  capacity 
of  the  various  heads  of  departments,  upon  whose  intelli- 
gence and  integrity  much  depends,  ought  to  receive 
the  first  consideration  as  a  candidate  for  an  advanced 
position.  When  a  superintendent  is  selected  from  the 
staff  there  follows  little  occasion  for  suspense  on  the 
part  of  the  working  force,  whereas  when  a  hospital  is 
placed  in  charge  of  an  outside  man,  considerable  time  is 
usually  required  for  the  readjustments  which  naturally 
follow.  Besides,  when  it  is  the  rule  of  an  institution 
that  worthy  assistants,  if  qualified,  will  be  promoted  as 
vacancies  occur,  ambitious  men  will  the  more  readily 
turn  to  this  line  of  work.  They  will  regard  such  prom- 
ises for  the  future  as  strong  inducement  to  enter  the 
service,  and,  once  engaged,  they  will  work  the  more 


36  CARE   OF  THE   INSANE 

diligently  to  perfect  their  knowledge  and  fit  themselves 
for  the  duties  of  the  advanced  positions. 

While  it  is  a  practical  impossibility  for  a  superin- 
tendent to  become  an  expert  in  all  departments  of 
medicine,  he  should  be  well  grounded  in  the  general 
science  of  medicine  and  have  special  interest  in  all  that 
pertains  to  nervous  and  mental  disorders.  In  large 
hospitals  the  assistant  physicians  will  necessarily  have 
to  take  charge  of  details  in  the  clinical,  psychiatric  and 
pathological  work.  But  the  superintendent  is  often 
obliged  to  express  opinions  and  make  decisions  on  med- 
ical questions  of  a  wide  range,  and  he  has  to  accept, 
by  virtue  of  his  position,  the  responsibility  attending 
whatever  measures,  medical,  hygienic  and  disciplinary, 
that  anyone  introduces  under  his  management.  He 
must  therefore  inform  himself  concerning  the  essential 
contents  of  a  wide  range  of  medical  Hterature,  and  inter- 
est himself  in  all  that  affects  the  preceptions  and  judg- 
ment of  those  physicians  engaged  in  treating  mental 
disorders.  If  especially  interested  in  scientific  medi- 
cine and  appreciative  of  the  superior  opportunities  for 
research  work  afforded  by  the  large  aggregation  of 
permanent  patients  always  found  in  hospitals  for  the 
insane,  he  will  not  rest  content  unless  competent 
workers  on  his  staff  are  engaged  in  laboratory  studies, 
searching  for  the  origin  of,  and  the  cause  for,  disease,  as 


CARE  OF  THE  INSANE  37 

well  as  deciding  the  multitude  of  clinical  conditions 
which  arise  in  the  wards.  Although  the  superintendent 
may  be  unable  to  devote  sufficient  time  to  any  one  line 
of  scientific  work  to  master  details  and  dictate  the 
measures  to  be  adopted,  still  all  department  workers 
should  be  subordinate  to  his  authority  in  respect  to 
appointments  to  the  positions,  the  general  scheme  of 
investigations  to  be  made,  and  in  all  matters  related  to 
discipHne.  Without  such  a  superintendent,  command- 
ing the  whole  hospital  organization,  whose  authority  is 
recognized  and  respected  by  all,  harmony  of  depart- 
ment labors  and  interests  cannot  be  secured  and  a 
systematic  development  of  the  institution  work  cannot 
be  expected. 

For  the  same  reason,  it  is  not  advisable  to  place  the 
general  business  affairs  of  the  hospital  under  the  con- 
trol of  a  steward  or  manager  acting  independently 
of  the  superintendent's  authority.  True,  the  medical 
head  of  the  modern  large  hospital  for  the  insane,  if 
attentive  to  medical  matters,  hospital  discipline  and 
the  personal  welfare  of  the  patients,  cannot  be  expected 
to  note  with  minute  oversight  the  daily  financial  trans- 
actions of  the  institution.  He  cannot  keep  himself 
posted  upon  market  fluctuations  and  perfect  his  judg- 
ment regarding  the  quality  and  intrinsic  value  of  food- 
stuffs, fabrics  and  other  commodities,  which  are  being 


38  CARE  OF  THE  INSANE 

replenished  constantly  and  in  wholesale  quantities.  But 
he  should,  as  a  matter  of  duty,  interest  himself  at 
times  in  the  quantity  and  quality  of  suppHes  pur- 
chased, see  that  the  purchasing  agent  proportions  his 
current  expenses  to  the  yearly  financial  resources,  and 
be  ready  at  all  times  to  counsel  the  official  buyer  and, 
when  necessary,  to  assume  responsibility  for  any  im- 
portant business  transactions.  When  the  superinten- 
dent is  the  recognized  chief  over  all  hospital  depart- 
ments, he  can,  as  he  deems  fitting,  delegate  to  a  steward 
all  the  latitude  and  authority  necessary  for  his  semi- 
independent  business  activities,  and  be  able  at  the  same 
time,  upon  occasion  or  necessity,  to  supplant  his  passive 
attitude  towards  the  purchasing  agent  with  positive 
vetoes  and  commands.  And  this  he  can  do  without 
scruple  or  risk  of  friction,  when  the  business  depart- 
ment is  officially  subordinate  to  the  superintendent. 
It  must  be  admitted  that  hospital  affairs  have  been 
successfully  conducted  under  the  divided  executive 
system  and  apparently  without  developing  jealousies. 
But  such  happy  issues  under  the  vexatious  dual  system 
are  exceptional  and  depend  upon  the  fortunate  per- 
sonality of  both  the  medical  and  the  lay  director,  who 
usually  attempt  to  administer  the  affairs  of  a  hospital 
unit  thus  organized  not  conjointly  but  working  inde- 
pendently of  each  other;  each  controlling  separate  sec- 


CARE  OF  THE  INSANE  39 

tions  where  cleavage  is  imperfect  and  duties  tend  to 
overlap,  where  individual  interests  are  certain  to  con- 
flict, and  where  arbitrary  trustee  rules  become  necessary 
to  establish  the  bounds  of  each  man's  province. 

When  asylums  for  the  insane  were  first  estabhshed  in 
this  country,  the  then  prevalent  English  system  of  man- 
agement was  adopted.  A  resident  physician  or  medi- 
cal superintendent  was  appointed  to  treat  and  manage 
the  patients;  but  a  lay  superintendent,  or  steward, 
was  quartered  upon  the  premises  and  all  business 
affairs  were  conducted  under  his  independent  authority. 
Among  the  other  duties  of  this  non-medical  head  was 
the  employment  and  official  discharge  of  attendants 
and  nurses.  Under  that  form  of  management,  in  those 
days,  it  was  generally  understood  that  an  irritating 
degree  of  hospital  discord  was  the  result.  The  medical 
head  chafed  under  a  sense  of  injured  dignity,  finding 
his  plans  frequently  obstructed  and  the  scope  of  his 
ambitious  ideals  restricted  in  ways  that  provoked  re- 
sentment and  effectually  humiHated  many  worthy  but 
sensitive  medical  superintendents.  When,  as  was  the 
usual  case,  the  trustees  maintained  more  intimate  rela- 
tions with  the  business  than  with  the  medical  head,  the 
professional  man  had  no  recourse  and  perforce  exhausted 
much  of  his  power  for  better  things  in  suppressing  sour 
complaints  and  imagining  the  happy  outcome  possible 


40  CARE  OF  THE  INSANE 

under  more  agreeable  and  more  favorable  conditions 
of  management.  If  there  ever  existed  any  substantial 
reason  for  the  adoption  of  such  schemes  of  hospital 
control,  calculated  chiefly  to  discredit  the  executive 
and  business  ability  of  the  professional  official,  its  vaKd- 
ity  was  never  admitted  by  medical  men.  In  recent 
times,  public  opinion  on  this  question  has  changed  so 
radically  that  nearly  all  large  hospitals,  those  treating 
general  diseases  as  well  as  the  special  institutions,  are 
now  placed  in  charge  of  superintendents  possessing  a 
medical  education  and  a  doctor's  degree.  When  such 
a  superintendent  in  a  general  or  special  hospital  is 
assigned  no  active  medical  duties,  still  his  medical 
training  is  regarded  as  an  essential  quahfication  for  the 
position,  as  it  alone  enables  him  to  clearly  comprehend 
the  aims  and  objects  of  the  organization  as  a  whole 
and  to  harmonize  the  interests  and  adjust  the  activi- 
ties of  the  several  departments.  His  technical  knowl- 
edge tends  to  eHminate  friction,  as  it  inclines  him  to 
cooperate  with  the  staff  physicians  and  enables  him  to 
recognize  the  necessity  of  numerous  but  important 
accessories  which  are  requisite  to  perfect  the  hospital 
equipment. 

But  the  education,  medical  and  general,  possessed  by 
a  hospital  superintendent  is  of  little  avail  unless  he  is 
gifted  with  native  talent  for  executive  work.     Genuine 


CARE  OF  THE  INSANE  41 

executive  ability  can  scarcely  be  acquired,  although  the 
cultivation  of  natural  aptitude  increases  its  efficiency. 
It  is  the  inborn  faculty  of  recognizing  things  in  their 
correct  relation  to  each  other;  of  seeing  at  a  glance 
where  and  when  to  initiate  action  which  will  naturally 
produce  desired  results.  It  is  that  variety  of  abihty 
which  enables  some  men  to  utilize  advantageously  the 
combined  services  of  others  in  working  out  the  details 
of  broad  plans.  It  is  an  instinctive  capacity  to  appre- 
hend causes,  to  marshal  events,  and  to  select  competent 
men  for  each  post  of  duty,  and  depends  upon  a  fertile 
imagination  controlled  by  logical  mental  processes. 

A  superintendent  should  possess  quick  and  accurate 
perceptions  so  he  can  acquire  and  assimilate  informa- 
tion rapidly.  He  should  employ  his  time  to  advantage, 
and,  to  cover  the  whole  field  of  his  interest,  he  should 
be  able  to  note  mentally  the  chief  or  accidental  details 
of  whatever  requires  even  his  momentary  attention. 
He  must  be  able  to  store  his  mind  with  a  large  fund  of 
knowledge  and  comprehend  practical  results  without 
adopting  the  slow  process  of  asking  questions.  Com- 
mendable business  prudence  on  his  part  should  be  self- 
evident  in  his  reports  to  trustees  and  his  everyday 
intercourse  with  those  who  have  business  relations  with 
the  hospital. 

To  command  respect,  a  superintendent  must  be  a 


42  CARE  OF  THE  INSANE 

wise  disciplinarian.  The  glory  of  a  large  hospital  or- 
ganization depends  upon  its  machinelike  action  in  pro- 
ducing results  of  a  high  order.  Human  beings  in  a 
mass,  each  with  individual  opinions  and  interests,  are 
brought  into  active  association  for  a  common  purpose. 
Officers  of  various  ranks,  several  grades  of  employees 
and  a  large  community  of  irresponsible  patients  must 
here  adjust  their  several  relations,  each  with  others; 
living  in  concord  and  working  in  harmony  for  purposes 
which  the  superintendent  formulates.  Orders  emanat- 
ing from  this  supreme  official  should  stimulate  and  regu- 
late activities  at  every  post  and  in  all  grades  of  the 
organization.  If  the  working  of  the  system  appears  to 
be  automatic,  if  only  the  regularity  and  smoothness  of 
the  daily  movements  attract  attention,  and  if  happy 
results  only  are  realized,  then  it  may  be  safely  assumed 
that  the  person  in  command  is  a  good  executive  and  a 
thorough  disciplinarian;  firm,  judicious,  and  consistent 
in  exercising  his  authority.  In  this  sphere  of  duty  the 
superintendent  must  assert  his  sovereignty,  command 
obedience,  reprove  inefficiency,  reward  the  faithful,  and 
trust  his  own  judgment.  Circumstances  often  compel 
him  to  delegate  more  or  less  power  to  subordinates,  yet 
he  will  have  to  accept  responsibility  for  all  orders  and 
decisions  thus  given  in  his  name.  It  is  therefore  very 
important,  considering  his  interests  and  reputation  as 


CARE  OF  THE  INSANE  43 

well  as  the  comfort  and  satisfaction  of  his  staff,  that  all 
who  come  into  official  contact  with  him  should  clearly 
understand  his  views,  his  methods  of  reasoning  and  his 
theories  concerning  rewards  and  penalties.  Members 
of  his  staff  should  be  able  to  predict  how  he  would  act 
in  case  any  given  hospital  rule  were  violated.  This  is 
possible  only  when  his  system  of  discipline  is  based  upon 
well-established  principles,  consistently  interpreted.  In 
his  conduct  towards  others,  officials,  employees  and  pa- 
tients, he  should  aim  to  be  just.  Then  let  his  process 
of  discrimination  be  accurate  and  he  will  soon  establish 
in  the  minds  of  his  associates  a  reputation  for  righteous 
deahngs  which  everyone  can  comprehend  and  his  sub- 
ordinates may  copy.  All  men  respect  him  whose  acts 
bear  the  hall  mark  of  rectitude,  and  have  no  difficulty 
in  deciding  what  attitude  such  a  person  would  take 
imder  any  known  circumstances.  If  a  superintendent 
allows  personal  timidity,  favoritism  or  prejudice  to 
warp  his  judgment,  if  he  temporizes  with  offenders 
because  of  their  threats  to  seek  revenge  or  because 
inconvenience  to  the  management  will  result  if  such  are 
discharged,  if  two  employees  commit  like  misdemeanors 
and  one  is  discharged  while  the  other  is  retained  in 
service  because  of  his  musical  or  ball-playing  ability, 
confusion  will  follow.  Subordinates  in  the  hospital 
will   thereafter   evade   questions   of   discipline,   ignore 


44  ;  CARE  OF  THE  INSANE  ' 

minor  faults,  and  defer  judgment  in  more  serious  cases. 
As  nothing  more  quickly  vitiates  discipline  than  dis- 
charging employees  unjustly,  the  superintendent  should 
make  certain  that  he  fully  comprehends  the  situation 
before  extreme  action  is  taken.  It  is  especially  fortu- 
nate if  one,  in  a  responsible  position,  has  the  capacity 
for  correctly  and  promptly  reading  human  nature,  as 
it  greatly  aids  in  reaching  conclusions  regarding  per- 
sonal reliabihty  and  merit.  Occasionally  it  may  be 
expedient  to  make  an  exception  to  an  estabHshed  rule, 
but  the  neglect  or  abuse  of  a  patient  should  never  be 
overlooked  or  excused.  The  superintendent's  respon- 
sibility for  the  custody  and  proper  treatment  of  large 
numbers  of  defenseless  patients  under  exposed  condi- 
tions admits  of  no  deviation  from  the  rule. 

In  managing  patients  some  show  of  discipline  must 
be  observed,  but  rigid  and  severe  measures  should  never 
be  adopted,  except  as  a  last  resort,  after  mild  methods 
have  been  found  unavailing.  Under  all  circumstances, 
mildness,  consideration  and  mercy  should  characterize 
the  enforcement  of  discipline  with  insane  patients.  It 
should  be  remembered  that  if  they  were  legally  respon- 
sible they  would  be  elsewhere.  If  such  persons  retain 
moral  responsibility  of  any  degree,  it  is  wise  to  culti- 
vate what  exists  rather  than  submerge  it  in  feelings  of 
bitter  resentment.     The  superintendent's  relations  with 


CARE  OF  THE  INSANE  45 

his  patients  include  that  of  '4n  loco  parentis."  His 
established  reputation  for  high  ideals  of  manliness  and 
justice  is  the  only  guarantee  which  the  public  can  de- 
pend upon  that  the  inmates  of  hospitals  for  the  ins^r-  ^ 
will  be  kindly  and  properly  treated.  They  are  in  his 
keeping.  They  class  legally  as  children,  and  it  is  his 
solemn  duty  to  protect  them  in  those  privileges  ana 
rights  which  the  state  especially  bestows  through  their 
commitment  to  his  care.  Thus  are  their  legal  rights 
estabHshed,  and  all  should  recognize  that  their  moral 
rights  are  vastly  increased  because  of  their  helplessness 
and  the  legal  restrictions  to  which  they  are  subjected. 
As  regards  personal  conduct  in  hospitals  for  the  insane, 
the  superintendent  is  lawgiver,  judge,  jury  and  sheriff. 
But,  above  all,  he  should  be  the  guardian  of,  and  advo- 
cate for,  the  patients.  Let  justice  requite  the  faults 
of  the  patients  as  well  as  those  of  the  employees;  but, 
in  the  case  of  the  patients,  let  it  not  be  a  bhndfolded 
dispenser  of  law,  such  as  is  suggested  by  the  conven- 
tional, emblematic  statue  of  Justice,  but  rather  a  clear, 
open-eyed  apostle  of  recompense,  who,  through  humane, 
compassionate  sentiments,  recognizes  that  their  calam- 
itous mental  condition  totally  changes  the  nature  and 
degree  of  individual  responsibility  in  the  case  of  the 
insane. 

Unless  a  superintendent's  attitude  towards  his  pa- 


46  CARE  OF   THE  INSANE 

tients  is  inspired  by  a  warm  heart,  and  unless  his  in- 
terest in  their  condition  and  needs  is  tinctured  with 
spontaneous  sympathy,  his  power  for  good  in  his  own 
institution  will  be  seriously  restricted.  But  his  sym- 
pathies must  be  of  the  rational,  intelligent  order  that 
color  and  soften  his  judgments  and  commands;  not 
the  blind,  hysterical  sort  that  will  sacrifice  an  ultimate 
good  for  temporary  emotional  satisfaction.  Occasions 
will  arise,  no  doubt,  when  the  sympathetic  inclination 
must  be  overruled,  but  usually  it  will  suggest  the  better 
policy,  produce  most  comfort  and  the  best  results.  In 
state  hospitals  there  will  always  be  a  large  class  of 
inmates  who  require  little  if  any  medical  treatment, 
but  whose  mental  distress  and  sense  of  loneliness  can 
be  largely  effaced  through  the  agency  of  sympathetic, 
moral  treatment.  And  such  treatment  must  be  adopted 
and  persistently  practiced  by  those  who  endeavor  to 
avoid  the  employment  of  mechanical  restraint.  The 
spirit  of  the  man  in  authority  can  but  affect  each  person 
within  the  circle  of  his  rule,  and  therefore,  if  a  super- 
intendent is  possessed  of  large  sympathies  and  has  the 
courage  to  exercise  them,  he  cannot  fail  to  soften  the 
views  of  his  subordinates  and  thus  aid  all  who  depend 
upon  him.  He  must  have  the  courage  to  give  and  the 
courage  to  withhold  as  circumstances  appeal  to  his 
judgment.     But  in  all  his  dealings  with  subordinates 


CARE   OF  THE  INSANE  47 

and  patients  he  should  be  positive.  He  should  have 
well-grounded  convictions  and  the  courage  to  shape  in 
accordance  therewith  his  own  life  and  their  line  of  duty. 
He  should  cherish  high  ideals  and  expend  energy  in 
striving  to  reach  his  adopted  goal.  His  success  will 
largely  depend  upon  his  native  fortitude.  If  he  at- 
tempts to  cross  the  channels  of  institutional  habits, 
however  unwisely  established  and  blindly  followed,  or 
if  he  proceeds  to  substitute  the  "non-restraint"  system 
for  the  long-used  strait-jacket  and  isolation  cell,  there 
will  be  serious  obstacles  to  overthrow,  plausible  argu- 
ments to  refute,  and  institutional  inertia  to  remedy  and 
energize. 

If  accidents  occur  under  the  workings  of  new  methods 
which  he  had  adopted  upon  convictions  as  to  their 
beneficial  results,  he  should  be  resolute  enough  to  de- 
fend his  working  principles.  Let  him  modify  and  per- 
fect his  details,  if  necessary,  but  defend  a  system  which 
he  knows  to  be  correct  and  work  with  ripened  experi- 
ence and  renewed  faith.  The  long-delayed  reform  in 
the  treatment  of  the  insane  is  explained  by  the  lack  of 
courage  on  the  part  of  the  old-time  custodians.  They 
feared  to  act  contrary  to  tradition,  and  saw  no  reason 
why  they  should  voluntarily  assume  burdens  of  respon- 
sibility for  the  sake  of  helpless  and  friendless  insane 
persons.    Public  opinion,  intrenched  in  old  supersti- 


48  CARE  OF  THE  INSANE 

tions  and  trammeled  by  fear  and  timidity  in  respect  to 
mental  disorders,  approved  the  most  galling  methods 
of  restraint.  Security,  not  restoration,  seems  to  have 
been  the  only  object  for  which  the  insane  were  seques- 
tered and  the  only  motive  which  consigned  mental 
invalids  to  lives  of  horror  within  prison  dungeons. 
When  no  one  questioned  the  propriety  of  tying  the 
hands  and  feet  of  an  insane  man,  strapping  him  firmly 
to  beds  and  chairs,  or  chaining  him  securely  to  the 
wall,  custodians  conceived  of  no  reason  why  inmates 
under  their  watch  and  care  should  be  permitted  to 
destroy  clothing  or  get  an  opportunity  for  escape  or 
suicide.  Pubhc  sentiment  was  unenlightened  with  re- 
spect to  the  necessity  for  this  condition  of  affairs,  and 
the  feehngs  even  of  religious  people  towards  the  in- 
sane were  hostile.  What  the  insane  have  suffered 
through  the  absence  of  sympathy  and  courage  on  the 
part  of  those  whose  duty  it  was  to  protect,  cherish  and 
cure  them,  we  cannot  adequately  realize.  May  the 
future,  by  humane  and  kindly  methods  of  treating  the 
insane,  atone  in  some  measure  for  past  neglect  and 
wrong!  Tuke  was  sympathetic  and  courageous  when 
he  took  the  Quaker  insane  out  of  the  government  asy- 
lums and  treated  them  in  the  York  Retreat  like  sick, 
inoffensive  children.  Pinel  exhibited  heroic  courage 
when  he  removed  from  the  insane  in  Salpetriere  the 


CARE  OF  THE  INSANE  49 

irons  and  chains  which  they  had  worn  for  years,  espe- 
cially when  in  doing  so  he  had  to  defy  official  protests 
and  ignore  universal  predictions  of  resulting  confusion, 
accidents  and  even  homicides. 

Medical  officers  in  all  hospitals  for  the  insane  fre- 
quently come  into  relation  with  cases  calling  for  coura- 
geous action.  Within  comparatively  recent  years  a  male 
patient  was  released  from  an  isolation-room  in  a  New 
England  hospital  after  he  had  been  kept  in  seclusion 
about  thirty  years  because  of  his  hostile  demonstrations 
and  repeated  acts  of  ferocity.  Prior  to  his  attack  of 
mental  disease  he  was  a  prominent  lawyer,  and  he  firmly 
beheved  his  confinement  was  illegal.  In  the  presence 
of  hospital  officials,  attendants  and  visitors  he  always 
protested  against  the  fancied  injustice  of  being  kept 
with  the  insane.  By  way  of  expressing  his  vehement 
objections  to  hospital  imprisonment,  he  spent  hours 
daily  kicking  the  heavy  oaken  door  which  prevented 
his  egress.  So  long-continued  and  so  vigorous  had  been 
this  habit  that  considerable  deformity  of  both  feet  had 
resulted.  Finally  a  resolute  assistant  physician  termi- 
nated the  isolation  of  this  long-feared  maniac  and  he 
was  permitted  to  mingle  freely  with  other  patients  in 
the  general  ward  and  upon  the  hospital  lawn.  He  injured 
no  one,  and  within  two  months  could  have  been  seen  en- 
gaged in  ball  playing  with  other  patients  on  the  grounds. 


50  CARE  OF  THE  INSANE 

At  a  still  more  recent  date  and  in  another  New  Eng- 
land hospital  a  young  medical  officer  who  possessed  the 
courage  to  act  upon  his  convictions  removed  from  the 
wrists  of  a  patient  manacles  which  had  been  worn  for 
many  years,  because  the  other  hospital  officials  had  mis- 
judged the  patient's  mental  attitude  and  magnified  his 
capacity  for  vicious  conduct.  The  irons  had  been  worn 
so  long  that  rust  prevented  their  removal  by  the  use  of 
a  key,  and  the  arts  of  the  blacksmith  were  required  to 
unshackle  the  man.  During  his  subsequent  hospital 
history  this  patient  gave  no  trouble  whatever. 

Every  superintendent  who  has  inaugurated  radical 
improvements  in  the  management  of  the  insane  has 
been  proclaimed  a  fanatic  by  timid  officials  and  criti- 
cal onlookers,  until  practical  success  demonstrated  the 
wisdom  of  his  innovations.  To-day,  while  politicians 
and  the  pubHc  press  assume  to  work  for  the  benefit  of 
the  inmates  of  hospitals,  their  narrow  views  of  hospi- 
tal methods  and  their  hasty,  ill-considered  criticisms  of 
hospital  management  through  inordinate  desires  to  gain 
sensational  notoriety  actually  increase  restrictions  upon 
the  insane,  since  they  often  overawe  and  intimidate 
superintendents  who  desire  to  extend  more  freedom  and 
parole  to  insane  patients  in  hospitals. 

It  is  good  fortune  for  all  concerned,  both  officials  and 
patients,  if  a  medical  superintendent  is  possessed  of  a 


CARE  OF  THE  INSANE  51 

sanguine  temperament  and  is  dominated  mentally  by 
optimism  —  not  the  fanatic  sort,  but  a  spontaneous  spirit 
of  hopefulness  which  conforms  to  practical  experience 
and  is  regulated  by  common  sense.  Often  his  line  of 
duty  and  progress  will  be  blocked  by  obstacles  formi- 
dable enough  to  thwart  his  best  intentions  unless  he 
is  gifted  with  an  overmastering  tendency  to  prefigure 
mentally  the  blessings  and  benefits  certain  to  follow 
perseverance  in  the  course  he  had  carefully  mapped  out. 
If  he  have  faith  in  his  own  judgment  and  confidence  in 
his  ability  to  attain  success,  he  will  overcome  all  oppo- 
sition by  persistent  struggles.  When  the  opposition  is 
too  strongly  intrenched  for  direct  attack,  he  will  devise 
a  flank  movement  and  succeed  through  skillful  man- 
euvers. Optimism  dissolves  doubt,  countervails  timid 
advice,  lifts  one  above  the  commonplace  grooves  of  rou- 
tine, and  favorably  modifies  the  force  of  traditional 
authority.  When  it  characterizes  a  superintendent's 
official  relations  with  his  medical  staff  and  lay  workers, 
their  mental  horizon  expands  and  their  desire  for  a  use- 
ful career  takes  on  fresh  vitality  because  of  the  expectant 
possibilities  before  them  which  his  optimistic  interpre- 
tation points  out.  It  is  the  basis  of  that  enthusiasm 
which  is  essential  to  the  most  successful  leadership. 
The  wise  master  avoids  the  arbitrary  tactics  of  the  boss, 
but  stimulates  the  aims  and  energies  of  his  subordinates 


52  CARE  OF  THE  INSANE 

through  persistent  and  consistent  presentations  of  the 
brilliant  prospects  ahead  which  invite  their  ambitious 
pursuit.  When  hospital  officials  and  employees  actually 
read  into  their  daily  toil  new  meanings  freighted  with 
promise  and  illumined  with  elevating  sentiments,  their 
capacity  for  labor  becomes  augmented  and  weariness 
from  effort  is  almost  abolished. 

Patients  who  fall  under  such  salutary  influences  are 
taught  to  cultivate  expectation,  and  to  foster  the  bright- 
est prospects  that  are  reasonably  within  their  grasp. 
By  this  process  of  sympathetic  encouragement,  some 
will  recover  hope  and  develop  a  faith  which  will  aid, 
if  not  engender,  the  process  of  recovery.  Many  cases, 
chronic  and  hopeless  as  regards  mental  restoration,  may 
thus  become  imbued  with  the  buoyant  spirit  and  pos- 
sibly find  comfort  in  the  reflection  that  their  condition 
might  possibly  have  been  worse  than  it  actually  is. 
Thus  the  superintendent's  feelings  and  spirit  are  diffused 
through  the  whole  hospital  group  and  his  optimistic  out- 
look may  glow  in  the  faces  and  mark  the  speech  of  both 
officers  and  patients,  to  such  a  degree  that  even  casual 
visitors  may  note  the  prevalent  tone  of  good  cheer  and 
hope  and  therein  discern  the  keynote  of  the  hospital  ad- 
ministration. A  pessimistic  physician  is  out  of  place  as 
the  head  of  a  hospital  for  the  insane.  His  constitutional 
tendency  to  look  for  and  dwell  upon  the  facts  and  cir- 


CARE  OF  THE  INSANE  53 

cumstances  of  a  disquieting  character  which  are  strik- 
ingly obvious  in  most  cases  of  insanity,  intensify  the 
morbid  propensity  of  despondent  patients  to  indulge 
ideas  and  reflections  which  are  most  painful  and  which 
prevent  or  retard  a  possible  recovery.  Then  the  over- 
shadowing, myopic  philosophy  expressed  in  the  phrase, 
"  What's  the  good?  "  smothers  the  happier  and  stimu- 
lating sentiments  which  alone  render  bearable  the  hos- 
pital existence  of  the  average  chronic  patient.  Under 
such  gloomy  supervision  the  ambitions  of  assistants  are 
checked  and  employees  view  their  obhgations  to  patients 
in  a  perfunctory  way.  In  all  enterprises  where  social 
questions  and  human  sentiments  are  involved,  the  cyni- 
cal, pessimistic  man  is  a  foredoomed  and  pestilential 
failure. 

Finally,  the  act  of  resigning  his  position  before  the  in- 
firmities incident  to  advancing  age  impair  his  executive 
abilities  is  a  supreme  test  of  a  superintendent's  wisdom. 
When  he  has  accompHshed  his  immediate  aim  and  done 
institutional  work  which  has  favorably  impressed  the 
medical  profession  and  the  general  pubKc,  he  will  be 
strongly  tempted  to  remain  in  the  service  too  long, 
living  upon  his  well-earned  reputation,  and  will  un- 
consciously fall  into  routine  operations  because  his 
potential  capacity  for  initiative  has  passed  its  meridian. 
Under  such  conditions,  he  can  add  nothing  to  his  fame 


54  CARE  OF  THE  INSANE 

and  may  impede  progress  which  younger  men,  stand- 
ing perhaps  upon  foundations  which  he  had  earlier 
established,  will  have  the  foresight  and  energy  to 
inaugurate.  When  a  man's  lifework  has  received  due 
acknowledgment  from  those  who  understand  the  situa- 
tion and  whose  judgment  is  valued,  he  may  retire 
satisfied;  and,  calhng  to  mind  the  fact  that  one  can- 
not expect  to  be  a  personal  power  for  leadership 
except  with  his  immediate  contemporaries,  he  should 
willingly  step  aside  and  open  an  opportunity  for  new 
men  with  fresh  energy  and  ambitious  aims.  His  ex- 
ample, his  fame,  his  high  purposes  and  good  works  are 
more  inspiring  to  others  than  would  be  his  continued 
efforts,  through  subsequent  years  of  dechning  physical 
and  mental  vigor.  Continual  progress  is  the  natural 
order  of  events  in  social  and  scientific  affairs,  and  the 
man  who  has  concentrated  his  attention,  year  after  year, 
upon  certain  lines  of  advance  has  probably  magnified 
his  objective  points  until  they  are  out  of  correct  propor- 
tion as  he  sees  them.  It  is  eminently  fitting,  therefore, 
that  medical  superintendents  with  a  record  of  long  ser- 
vice, especially  those  who  have  been  devoted  to  the  ad- 
vancement of  certain  features  of  management  and  have 
in  fair  measure  realized  their  ideals,  should,  before  cir- 
cumstances compel  abdication,  vacate  the  positions  with 
which  they  have  been  identified,  and  permit  successors 


CARE  OF  THE  INSANE  55 

to  enter  the  field  of  operations.  The  broad,  open- 
minded  ex-superintendent  should  in  the  end  find  his 
greatest  satisfaction  in  realizing  that  his  own  work  will 
be  utilized  by  those  who  come  after  him  as  a  stepping 
stone  to  still  higher  achievements;  in  cheering  on  those 
who  take  up  the  work  where  he  left  off;  and  in  the  serene 
conviction  that  they  will  estabhsh  greatly  desired  ad- 
vances in  medical  science  and  in  the  treatment  of  in- 
sanity which  he  could  but  fondly  anticipate. 


THE  MEDICAL  STAFF. 

Assistant  physicians  should  be  appointed,  or  pro- 
moted, only  upon  the  recommendation  of  the  superin- 
tendent. For  interested  trustees  or  practical  politi- 
cians to  force  the  nomination  of  a  particular  candidate 
against  the  free  judgment  of  the  superintendent  is  sub- 
versive of  that  discipline  which  he  must  maintain  if  his 
administration  is  to  command  respect.  In  settling  pre- 
liminary questions  regarding  appointments,  it  is  emi- 
nently proper  that  the  superintendent  should  confer 
with  trustees,  especially  with  medical  members  of  the 
board ;  but  the  fact  remains  that  he  can  best  decide  as 
to  the  kind  of  man  required  to  fill  the  vacant  post  and 
best  judge  of  the  candidates'  capabiHties,  notably  so 
in  cases  of  promotion. 

In  selecting  assistants,  great  care  should  be  exercised 
to  ascertain  the  facts  regarding  the  applicant's  character, 
his  habits,  his  guiding  principles  and  his  predominant 
sentiments.  A  record  for  brilliant  scholarship  should 
not  of  itself  be  permitted  to  outweigh  established  repu- 
tation for  sobriety,  truthfulness,  habits  of  industry, 
and  tenacity  of  purpose.  An  assistant  physician  whose 
word  cannot  be  depended  upon  is  a  stumbHng  block  for 

57 


58  CARE  OF  THE  INSANE 

the  management  and  a  menace  to  the  good  name  of  the 
hospital.  When  a  superintendent  relies  upon  the  word 
of  an  assistant  who  is  guilty  of  misrepresentation,  most 
painful  embarrassments  will  naturally  follow.  Patients 
even  distrust  and  condemn  untruthful  medical  assist- 
ants, and  the  friends  of  patients  resent  being  imposed 
upon  by  falsehoods  when  they  have  the  undoubted 
right  to  know  the  facts.  Then,  the  hospital  records 
kept  by  assistants  must  bear  the  stamp  of  honesty,  as 
scientific  work  is  impossible  when  the  medical  records, 
even  to  minute  details,  are  not  absolutely  reliable. 

Young  medical  men  should  feel  honored  when  they 
receive  a  hospital  appointment  and  strive  through  right 
conduct  and  honest  work  to  add  dignity  and  impor- 
tance to  the  position.  While  occupying  subordinate 
posts  they  should  be  loyal  to  their  superior  officers; 
not  because  tenure  of  office  may  depend  upon  such 
observances,  but  for  the  reason  that  fidelity  is  a  basic 
principle  of  true  manliness.  It  is  not  advisable  to  en- 
cimiber  the  personal  movements  of  staff  officials  with 
many  inflexible  rules  and  regulations.  Assistants  who 
cannot  be  trusted  to  regulate  their  general  conduct 
according  to  the  code  of  gentlemen,  who  cannot  treat 
employees  with  kindness  and  courtesy  without  sacri- 
ficing official  dignity,  and  those  who  on  the  hospital 
premises,  whether  on  duty  or  off  duty,  ignore  the  social 


CARE  OF  THE  INSANE  59 

distinctions  which  their  official  rank  confers,  ought  not 
to  be  promoted,  possibly  not  even  retained  in  the  service. 
Rules  outlining  duties  must  be  estabhshed  to  system- 
atize the  procedure  of  such  community  workers.  But 
men  competent  to  fill  staff  positions  must  have  out- 
grown the  necessity  for  petty  restrictions.  Their  plain 
obligations  and  sense  of  honor  should  suffice  as  ample 
guides  for  deportment.  However,  it  should  not  be  taken 
for  granted  that  the  burden  of  obligation  rests  wholly 
upon  assistant  physicians;  that  their  reasonable  claims 
for  faithful  labors  are  wholly  liquidated  by  a  meager 
salary. 

That  they  have  some  moral  claims  upon  the  manage- 
ment should  be  admitted.  When  they  voluntarily  sub- 
scribe to  the  supreme  authority  of  the  superintendent 
they  must  of  necessity  trust  him  to  pilot  them  wisely,  to 
instruct  them  in  the  best  methods  of  hospital  manage- 
ment, to  facilitate  their  quest  for  scientific  knowledge, 
and  to  assist  the  worthy  ambitious  in  securing  promotion 
either  imder  his  management  or  elsewhere  as  opportu- 
nity may  offer.  A  superintendent  who  in  his  relations 
with  his  assistants  rests  satisfied  upon  his  opportu- 
nities to  pose  for  admiration,  all  the  more  flattering 
if  mingled  with  envy,  violates  his  deeper  obhgations 
and  disregards  noblesse  oblige  inherent  in  his  official 
position.    Officially  and  socially,  he  should  treat  them 


6o  CARE  OF  THE  INSANE 

with  the  respect  due  members  of  his  official  family. 
He  should  encourage  them  to  rise  above  trivial  amioy- 
ances  and  personal  jealousies  which  too  frequently  in- 
vade official  families  in  public  institutions.  He  should 
make  it  emphatically  plain  to  their  comprehension  that 
the  first  and  highest  duty  of  every  hospital  official 
relates  to  the  care  and  treatment  of  the  patients,  pro- 
tecting them  from  abuse  and  promoting  their  restora- 
tion to  health  through  an  exhaustive  study  of  their 
cases,  scientific  treatment,  and  the  arts  of  a  true  phi- 
lanthropist. Young  physicians  entering  upon  staff 
duties  should  be  aided  to  adjust  themselves  to  the  re- 
quirements of  their  new  responsibilities.  Invested  with 
delegated  authority  from  the  superintendent,  they  will 
be  required  to  aid  in  enforcing  discipline,  and,  where 
''non-restraint"  of  patients  is  insisted  upon,  they  must 
feel  considerable  uncertainty  as  to  what  attitude  to 
take  where  perplexing  conditions  are  wholly  new  and 
their  experience  is  hmited.  If  they  are  inclined  to 
accept  the  views  and  conclusions  of  the  superintendent, 
it  will  require  time  and  numerous  observations  for  them 
to  clearly  apprehend  the  principle  of  ''non-restraint," 
the  great  importance  of  its  enforcement,  and  the  best 
methods  of  its  application  to  the  ordinary  and  extraor- 
dinary incidents  which  daily  occur  in  the  hospital 
wards.    For  a  time  they  can  do  no  better  than  respect 


CARE  OF  THE  INSANE  6l 

the  superintendent's  scheme  of  management,  accept  his 
suggestions  and  refer  all  complicated  cases  to  him  for 
solution.  When  assistants  make  mistakes,  he  should 
take  the  first  occasion  to  analyze  the  faults,  point  out 
the  errors  and  explain  how  satisfactory  results  would 
have  followed  wiser  action  on  their  part.  If  a  second 
lesson  on  the  same  subject  becomes  necessary,  the  super- 
intendent should  make  his  instructions  sink  deeper  if 
possible.  When  circumstances  will  allow  consideration 
to  be  shown,  even  a  serious  mistake,  if  honestly  re- 
gretted by  the  assistant,  may  be  overlooked;  yet  it 
should  be  made  plain  that  a  repetition  of  serious  blun- 
ders could  not  be  condoned. 

It  is  impossible  for  a  superintendent  to  review  all  the 
doings  of  his  assistants,  but  new  men  should  be  cau- 
tioned against  the  too  free  employment  of  drug  medi- 
cation. Young  men  fresh  from  the  schools  incline  to 
prescribe  hypnotics  to  excess,  and  to  use  hypodermic 
needles  too  freely. 

The  details  of  ward  work  must  be  left  to  the  assist- 
ants, but  the  superintendent  must  retain  oversight  and 
discharge  his  obligations  to  both  assistants  and  patients. 
So  far  as  the  professional  medical  work  applies,  he  can 
best  serve  both  parties  by  adopting  the  practice  of  a 
daily  clinic  to  be  conducted  each  morning  by  the  assist- 
ant physicians  under  his  supervision.     In  no  other  way 


62  CARE  OF  THE  INSANE 

can  he  take  time,  with  his  many  executive  duties,  to 
thoroughly  satisfy  himself  that  the  physical  and  mental 
state  of  each  patient  has  been  carefully  investigated; 
that  complete  and  reliable  records  of  the  condition  of  all 
patients  are  being  promptly  made;  that  the  junior  mem- 
bers of  the  staff  understand  their  work  and  are  making 
satisfactory  progress  in  the  study  of  insanity.  In  short, 
every  large  hospital  for  the  insane  should  be  converted 
into  a  speciaHzed  medical  school  for  graduate  students, 
where  clinical  and  pathological  work  can  be  correlated 
and  pursued  to  the  best  advantage.  If,  through  the 
superintendent  or  the  laboratory  director,  a  close  con- 
nection with  the  teaching  force  of  some  not-too-distant 
medical  school  can  be  arranged,  the  association  may  be 
made  one  of  much  advantage  to  the  hospital  by  attract- 
ing students  to  the  special  work  of  hospitals,  stimulating 
members  of  the  staff  to  produce  better  results,  and  by 
giving  the  hospital  a  better  standing  among  members  of 
the  medical  profession. 

The  superintendent  should  see  that  every  patient 
entering  the  hospital  becomes  in  due  time  the  special 
V  subject  of  a  clinical  conference.  In  large  hospitals  with 
frequent  admissions  —  as  many  as  five  or  six  hundred 
new  cases  yearly  —  this  broad  system  of  clinical  demon- 
strations has  been  practiced  year  after  year  to  the  com- 
plete satisfaction  of  all  officials.     The  simplest  method  is 


CARE  OF  THE  INSANE  63 

to  list  in  two  classes,  male  and  female,  all  patients  ad- 
mitted. The  assistant  physicians  should  also  be  listed 
in  two  groups,  —  those  who  have  charge  of  the  male 
and  female  wards,  respectively.  Keeping  the  male  and 
female  departments  separate,  the  assistants  in  regular 
rotation  should  have  assigned  to  their  charge  the  patients 
in  the  order  of  their  enrollment  on  the  admission  books. 
By  this  arrangement,  favoritism,  collusion  and  selfish- 
ness are  guarded  against  and  each  doctor  has  a  fair  and 
equal  chance  of  getting  the  easy  and  the  interesting 
cases,  while  choice,  or  exchange,  of  cases  should  not  be 
permitted  except  with  the  superintendent's  approval. 
The  assignment  of  a  patient  to  a  particular  physician 
under  this  scheme  signifies  that  he  must  make  the  physi- 
cal and  mental  examinations,  ascertain  the  previous 
history  of  the  patient,  and  by  questions,  verbal  and 
written,  addressed  to  the  patient,  his  relatives  and 
friends,  accummulate  all  possible  information  that  bears 
upon  the  patient's  mental  endowment,  developmental 
epochs,  education,  youthful  and  adult  habits,  the  appar-  \J 
ent  cause  for  the  mental  disorder,  its  progress  and  its 
tendency  towards  recovery  or  dementia.  All  such  evi- 
dence, his  personal  observations,  etc.,  should  be  dic- 
tated to  a  stenographer,  or  recording  machine,  to  be  v 
typewritten  and  massed  together  in  the  individual  case 
portfolio.    A  careful  analysis  of  the  mental  condition 


64  CARE  OF  THE  INSANE 

should  be  given  and,  when  obtainable,  enough  of  the 
patient's  conversation,  answers  to  questions,  flight  of 
ideas,  incoherent  utterances,  etc.,  should  be  quoted  at 
sufficient  length  to  fully  illustrate  the  patient's  mental 
state.  The  diagnosis,  or  provisional  diagnosis,  should 
be  stated  and  a  differential  diagnosis  should  be  elab- 
orated and  recorded.  Work  of  this  sort,  when  done  with 
nice  discrimination,  will  add  much  to  the  value  and  in- 
terest of  the  hospital  records;  besides,  it  will  rapidly 
develop  the  examiner's  diagnostic  sense.  Finally,  he 
should  write  out  his  opinion  regarding  prognosis.  As 
soon  as  all  these  details  have  been  considered,  decided 
upon  and  t3^ewritten,  the  examiner  should  announce 
his  readiness  to  present  the  case  and  arrange  with  the 
superintendent  a  date  for  this  purpose.  Ordinary  cases 
can  be  properly  presented  in  thirty  minutes,  and  there- 
fore at  least  two  cases  should  be  in  readiness  for  each 
clinic. 

An  early  morning  hour,  prior  to  time  for  regular  ward 
visits,  affords  the  most  convenient  time  for  such  clinics. 
They  start  the  day's  work  promptly  and  in  a  decid- 
edly stimulating  way,  and  at  this  early  hour  the  super- 
intendent is  less  Hkely  to  be  called  away  by  visitors 
and  business  engagements.  Prompt  attendance  by  the 
whole  medical  staff  should  be  insisted  upon.  The  super- 
intendent should  regard  his  own  attendance  upon  the 


CARE  OF  THE  INSANE  65 

conference  as  imperative.  He  should  brook  no  delay- 
but  be  present  at  the  moment  appointed  and  preside  as 
at  a  formal  medical  meeting.  The  assembling  place 
should  be  near  the  main  office.  The  hospital  library 
often  proves  convenient,  but  a  room  with  abundant 
sunlight  should  be  selected  if  practicable.  When  the 
patients  are  too  excitable  or  too  infirm  to  be  transferred 
from  the  wards  for  clinical  demonstrations,  adjourn- 
ment to  the  patient's  room  or  bedside  can  be  ordered 
after  the  case  records  have  been  read  and  the  condi- 
tions explained.  Before  the  patient  is  brought  into  the 
presence  of  the  staff,  the  examiner  should  read  his  com- 
plete records  of  the  case.  Then,  producing  the  indi- 
vidual, if  in  suitable  condition,  he  should,  by  questions, 
explanations,  and  by  the  aid  of  various  tests,  demon- 
strate the  existing  evidence  of  mental  disorder  in  the 
case,  call  attention  to  nervous  conditions,  specify  indi- 
cations of  physical  defects  or  injuries,  and  point  out 
the  special  features  of  the  case  which  he  had  described 
in  the  history  and  explanations  previously  read.  It 
should  be  his  aim  to  convince  all  present  that  he  had 
properly  canvassed  the  case,  skillfully  grouped  the  salient 
symptoms  and  correctly  interpreted  their  significance. 
Then  the  other  assistants  present  should  be  at  liberty 
to  examine  the  patient,  ask  questions,  expose  addi- 
tional or  obscure  symptoms  if  detected.    When  all  pres- 


66  CARE  OF  THE  INSANE 

ent  have  availed  themselves  of  reasonable  opportu- 
nities in  this  respect,  the  patient  should  be  dismissed 
and  returned  to  his  ward  or  room.  As  soon  as  the 
patient  leaves,  the  superintendent,  or  the  temporary 
chairman,  should  call  upon  each  physician  in  turn  to 
express  his  opinion  of  the  case.  If  anyone  thinks  he 
has  observed  sufficient  evidence  to  warrant  the  venture, 
he  will  probably  regroup  the  distinctive  symptoms  and 
contend  for  a  diagnosis  different  from  that  advanced 
by  the  original  examiner.  Such  discussions  become  es- 
pecially interesting  and  instructive  when  arguments  are 
supported  by  quotations  from  recognized  authorities. 
The  substance  of  all  remarks  made  in  the  clinical  dis- 
cussion should  be  recorded  at  the  time  in  a  special 
journal  kept  by  the  staff,  each  member  in  turn  serving 
for  one  month  as  secretary,  unless  a  stenographer  can 
be  employed  for  this  service.  When  the  condition  of 
the  patient  subsequently  undergoes  a  marked  change, 
the  case  should  be  again  presented  at  a  staff  clinic,  and 
all  patients  should  be  thus  carefully  examined  immedi- 
ately before  their  discharge.  At  such  final  appearance 
before  the  staff  a  statement  covering  each  patient's  hos- 
pital experience  should  be  elicited  and  complaints  or 
fancied  grievances  should  be  fully  recorded.  This  staff- 
meeting  record  will  become  more  and  more  interesting 
as  time  lapses  and  will  be  consulted  surprisingly  often  as 


CARE  OF  THE  INSANE  67 

a  case  progresses,  is  discharged,  is  readmitted,  or  termi- 
nates by  death.  All  the  clinical  and  staff-meeting  rec- 
ords should  be  rendered  available  for  special  study  by 
a  suitable  card  index  carefully  kept.^  One  hour  a  day 
spent  in  such  staff -meeting  clinics  will  enable  the  super- 
intendent to  obtain  full  information  concerning  the 
patients  under  his  care,  to  make  certain  that  none  is 
overlooked  in  respect  to  such  critical  examinations,  and 
that  the  assistant  physicians  are  diligent  and  thorough 
in  their  professional  work.  The  fact  that  many  of  the 
cases  thus  written  up  and  discussed  will  eventually  be 
found  in  the  autopsy  room,  where  the  pathological  con- 
ditions can  be  definitely  determined,  when  and  where 
the  opinions  recorded  on  the  case  sheets  and  in  the  staff- 
meeting  journal  can  be  confirmed  or  refuted,  spurs  on 
each  physician  to  do  his  best  work,  and  continuous  work 
of  such  a  character  perfects  his  medical  education. 

The  fact  that  a  physician  examines,  watches  over  and 
reports  a  case  does  not  necessarily  consign  that  case  to 
wards  over  which  he  presides.  The  condition  of  the 
case  will  probably  determine  its  classification  and  ward 
location,  and  all  patients  in  a  given  ward  should  be 
managed  and  prescribed  for  by  the  assistant  in  charge 
of  that  division.  New  cases  as  a  rule  go  into  the 
reception  wards,  and  consequently  all  the  assistants 
*  See  Card  Index  in  Appendix. 


68  CARE  OF  THE  INSANE 

will  have  patients  under  special  observation  in  the  male 
or  female  admission  wards  at  the  same  time,  as  each 
man  must  follow  his  cases,  at  least  during  the  acute 
stage  or  until  he  has  completed  the  preHminary  case 
records  and  presented  the  case  at  the  clinic.  This 
system  permits  every  man  on  the  staff  to  engage  in 
studying  fresh,  acute  cases,  even  when  his  regular  ward 
duties  are  in  sections  of  the  hospital  occupied  by  chronic 
patients.  It  might  be  supposed  that  such  a  mixed 
arrangement  would  result  in  friction  between  members 
of  the  staff,  but  where  the  scientific  spirit  is  properly 
encouraged  jealousies  are  dispelled  and  the  men  work 
side  by  side  in  peace  and  with  mutual  advantage. 
Although  no  one  can  predict  in  advance  whether  any 
particular  case  will  eventually  be  the  subject  of  an 
autopsy,  it  becomes  necessary  to  prepare  the  clinical 
records  of  every  case  with  sufficient  care  to  render 
them  available  and  useful,  provided  the  autopsy  ever 
does  occur.  A  searching  examination  should  therefore 
be  given  every  case,  and  under  that  practice  no  case, 
however  forlorn  or  demented,  is  uninteresting.  Nearly  all 
the  patients  are  pleased  by  having  their  condition,  their 
infirmities  even,  made  the  subject  of  serious  investiga- 
tion, and  the  friends  of  such  patient's  always  appreciate 
the  special  interest  shown  by  critical  examinations. 
Junior  assistants  should  commence  to  take  their  share 


CARE  OF  THE  INSANE  69 

of  assigned  cases  early  in  their  hospital  service,  and  in- 
ternes, if  graduates  or  advanced  medical  students,  should 
take  some  cases  for  practice  in  making  examinations, 
writing  histories  and  conducting  clinical  demonstra- 
tions. Inexperienced  men  will  for  a  time  require  some 
aid  and  suggestions  in  this  work,  but  the  necessary 
help  can  always  be  obtained  from  the  experienced 
senior  assistants. 

Staff  physicians  devoted  to  laboratory  work  should 
attend  the  morning  clinics,  taking  part  in  the  discus- 
sions, and  express  opinions  when  called  upon;  but  unless 
they  are  anxious  to  spend  time  in  studying  psychi- 
atry they  may  as  well  be  excused  from  making  case 
examinations  and  clinical  demonstrations.  Their  spe- 
cial field  of  work  renders  it  encumbent  upon  them  to 
make  the  laboratory  examinations  and  findings  inter- 
esting and  profitable  to  the  clinical  assistants.  One  or 
more  evenings  each  month  should  be  set  apart  for  lab- 
oratory staff  meetings,  at  which  the  laboratory  chief, 
by  the  aid  of  microscopes,  or,  what  serves  the  purpose 
much  better,  a  projection  apparatus,  should  exhibit  tis- 
sue changes  in  the  brain  and  body  organs  as  found 
in  recent  post-mortem  subjects.  In  connection  with 
the  display  of  pathological  conditions,  let  him  review  the 
clinical  records  in  the  cases  represented  and  note  the 
erroneous,  as  well  as  the  correct,  diagnoses  therein  re- 


70  CARE  OF  THE  INSANE 

corded  by  the  clinical  workers,  and  again  they  are 
reminded  of  the  importance  of  wide  and  accurate  medi- 
cal knowledge  as  well  as  of  skill  in  applying  it.  When 
the  members  of  the  medical  staff  realize  the  advantage 
they  derive  from  thorough  autopsy  work  and  interest 
themselves  in  obtaining  permission  from  the  relatives 
for  such  examinations,  consent  can  be  secured  in  more 
than  half  the  deceased  cases;  and  when  assistant  phy- 
sicians have  every  reason  to  expect  that  at  least  fifty 
per  cent  of  their  patients  will  eventually  be  subjected 
to  post-mortem  and  microscopic  examinations,  that 
any  one  of  the  many  patients  under  their  care  may 
by  chance  come  into  the  post-mortem  class,  their 
professional  work  will  be  done  with  the  utmost  care 
without  urging  or  nagging  from  the  superintendent. 
Requiring  such  exacting  work  of  assistants  will  not  be 
resented  by  men  of  ability  and  ambition,  as  they  must 
admit  that  thorough  examination  and  careful  treat- 
ment of  patients  are  reasonable  demands,  and  they  must 
also  realize  that  the  proficiency  they  acquire  by  such 
painstaking  examinations,  critical  discussions  and  clini- 
cal demonstrations  becomes  a  valuable  personal  asset 
of  their  professional  capital.  It  invests  them  with  such 
a  degree  of  confidence  and  self-rehance  that  they  can 
appear  with  credit  before  any  medical  society,  present- 
ing cases  and  taking  part  in  discussions. 


CARE  OF  THE  INSANE  71 

In  hospitals  where  careful  professional  work  is  done, 
the  physicians'  time  becomes  too  valuable  to  be  spent 
in  clerical  labors.  Even  internes  in  all  hospitals  should 
be  spared  such  time-wasting  work  as  writing  case  his- 
tories with  the  pen.  Dictating  to  a  stenographer,  or 
a  recording  machine,  not  only  economizes  time  but 
is  time  well  spent  because  it  rapidly  improves  one's 
diction. 

Another  line  of  duty  usually  imposed  upon  staff 
physicians  in  well-organized  hospitals  consists  in  giving 
lectures  to  nurses  in  the  training  school.  This  task 
should  be  welcomed,  as  the  practice  more  than  repays 
the  lecturer  for  all  the  mental  application  expended 
upon  that  work. 

Men  engaged  in  hospital  work  on  a  scientific  basis 
should  be  granted  liberal  vacations.  Many  of  their 
duties  are  exacting  and  nervously  exhausting,  and  where 
they  faithfully  work  out  their  case  histories  and  attend 
routine  ward  duties  they  require  frequent  resting  spells. 
Without  doubt  men  can  accomplish  more  first-class 
work  within  a  year,  when  at  least  one  month  is  given 
up  to  change  of  scene  and  relaxation  from  ofiicial  duty. 

Hospital  managers  make  a  mistake  if  they  allow  an 
assistant  physician  of  ability  and  promise,  with  a  satis- 
factory record,  to  resign  when  he  would  remain  in  the 
service  if  free  to  marry  and  suitable  apartments  were 


72  CARE  OF  THE  INSANE 

provided  for  him.  The  additional  expense  to  an  insti- 
tution incurred  by  caring  for  married  assistants  and 
their  families  is  usually  a  good  investment,  as  it  insures 
a  contented  ofi&cial  and  the  long-continued  services  of  an 
interested  and  experienced  man. 


HOSPITAL  LABORATORIES. 

The  laboratory  has  come  to  be  the  vital  center  of 
hospital  work,  as.  it  is  impossible  to  practice  medicine 
at  the  present  day  without  employing  laboratory  meth- 
ods to  determine  the  real  basis  for  many  physical  dis- 
orders. Pathogenic  bacteria  are  associated  with  so 
many  diseased  conditions  which  call  for  intelligent 
positive  management  that  apparatus  and  material  for 
bacteriological  cultures,  stains,  and  identifications  must 
be  conveniently  accessible  on  the  premises  unless  a 
public  board-of-health  laboratory  be  estabHshed  in  the 
vicinity.  Sooner  or  later,  every  large  institution  has  to 
cope  with  epidemics  of  germ  diseases,  —  typhoid  fever, 
diphtheria,  dysentery,  etc.  Having  at  command  labo- 
ratory facilities  for  determining  the  facts  regarding  the 
character  of  such  diseases,  their  precise  locality,  their 
extension  or  subsidence,  and,  by  reason  of  such  knowl- 
edge, being  able  to  apply  the  exact  remedy  in  the  right 
place  and  at  the  right  time,  mitigates  by  more  than 
half  the  worry  and  sense  of  responsibility  thrust  upon 
the  management  of  the  hospital  by  an  epidemic  out- 
break.    Then   the   most   delicate   blood   examinations 

73 


74  CARE  OF  THE  INSANE 

should  be  matters  of  daily  routine.  Diagnosing  certain 
diseases,  producing  autogenous  vaccines,  settling  ques- 
tions of  immunity,  controlling  dosage  in  the  specific 
treatment  of  tuberculosis,  etc.,  are  among  the  prob- 
lems which  the  laboratory  alone  can  decide  and  which 
ought  to  be  decided  within  each  institution. 

All  hospitals  should  be  able  to  keep  up  to  the  times 
with  pathological  work.  Specimens,  in  the  form  of 
mounted  microscopic  slides,  from  every  diseased  organ, 
in  all  cases  examined  post  mortem,  should  be  kept  in 
cases  so  marked  and  numbered  that  any  desired  one 
could  be  found  whenever  needed. 

Laboratory  equipments  in  connection  with  hospitals 
for  the  insane  suggest  the  propriety  of  making  research 
investigations  in  order  to  obtain  more  definite  knowl- 
edge regarding  the  causation  of  insanity.  The  physical 
cause  for  some  phases  of  insanity  may  be  one  of  the 
obscure  secrets  which  can  be  discovered  only  through 
experiments  with  the  blood  serum.  That  wonderful 
fluid  is  known  to  contain  and  retain  so  many  specific 
marvels  which  seem  not  to  interfere  with  one  another 
that  there  is  much  promise  for  light  upon  some  forms 
of  insanity  in  this  field  of  inquiry.  Few,  even  among 
physicians,  realize  the  superior  advantages  for  medical 
research  work  to  be  found  in  the  modern  large  hospital 
for  the  insane  where  a  complete  laboratory  outfit  is 


CARE  OF  THE  INSANE  75 

under  the  management  of  a  competent  corps  of  medi- 
cal specialists.  Very  often  the  enthusiastic  investiga- 
tor into  bio-chemical  secrets,  physiological  anomalies, 
pathological  conditions  and  causes,  works  upon  some 
important  problem,  isolated  from  interested  associates 
who  might  aid  him  in  excluding  the  personal  equation 
and  other  misleading  factors.  Frequently  he  is  handi- 
capped by  inadequate  laboratory  accessories,  or  searches 
vainly  for  material  enough  to  give  the  results  of  his 
labors  a  basis  sufficiently  broad  to  command  respectful 
attention.  But  in  large  state  hospitals  every  variety 
of  laboratory  implement  can,  and  should,  be  provided. 
Working  side  by  side  and  in  harmonious  efforts  to 
secure  a  better  understanding  of  the  diseases  they  are 
investigating  are  grouped  the  clinician,  the  chemist  and 
the  pathologist,  who  are  thus  able  to  control  or  supple- 
ment one  another's  work. 

Besides,  within  the  same  institution  walls  there  re- 
sides a  large  number  of  permanent  patients  under  their 
immediate  observation  and  absolute  control,  and  among 
this  aggregation  of  invalids,  case  after  case  of  some  dis- 
eased condition,  in  varying  stages  of  development,  can 
be  observed.  In  this  promising  field  they  can  work,  and, 
testing  out  theories  as  they  proceed,  they  can  establish 
on  a  practical  basis  any  discovery  made  and  verify  again 
and  again  any  claims  they  may  consider  worth  pub- 


76  CARE  OF  THE  INSANE 

lishing.  Research  medical  work  in  hospitals  for  the 
insane  in  its  results  cannot  be  restricted  to  that  which 
alone  interests  the  mental  specialist.  Any  new  fact 
established  through  scientific  work  there  will  be  of  such 
fundamental  character  that  it  will  enrich  the  literature 
and  extend  the  scope  of  general  medicine. 

Unfortunately,  hospitals  for  the  insane  are  often  re- 
garded as  undesirable  neighbors  in  a  town  or  locality. 
Be  they  popular  or  unpopular,  they  can,  in  a  large 
measure,  compensate  the  surrounding  public  for  their 
presence  by  generously  permitting  neighboring  physi- 
cians to  enjoy  in  their  private  practice  the  assistance 
which  the  hospital  laboratory  can  render.  Especially 
when  hospitals  which  maintain  first-class  laboratories 
are  situated  in  country  districts,  remote  from  centers 
where  board-of-health  laboratories  are  established  to 
aid  in  determining  many  health  questions  vital  to  the 
community,  they  should  extend  to  the  general  prac- 
titioners of  medicine  within  a  reasonable  distance  the 
benefits  of  the  laboratory  facilities  and  the  skill  of  the 
laboratory  staff.  Bacteriological  and  pathological  ques- 
tions from  such  outside  sources  should  be  fully  consid- 
ered and  the  best  expert  ability  should  be  at  the  service 
of  the  medical  men  outside  the  institution.  Possibly 
it  might  be  advisable  to  charge  for  such  work  the  act- 
ual expense  incurred.     But  if  rendered  gratuitously,  the 


CARE  OF  THE  INSANE  77 

hospital  would  profit  by  its  benevolent  intention,  since 
the  amount  of  outside  work  would  seldom  interfere 
with  regular  duties,  and  would,  while  interesting  and 
stimulating  the  laboratory  operators,  secure  the  good 
will  of  the  profession  and  general  pubhc.  Should  such 
outside  work  necessitate  the  services  of  an  extra  assist- 
ant, the  additional  expense  would  be  an  excellent  in- 
vestment for  the  citizens  at  large,  by  whom  such  insti- 
tutions are  owned  and  supported. 


MANAGEMENT  OF  PATIENTS. 

The  modern  large  hospital  for  the  insane,  palatial  in 
respect  to  its  proportions  and  architecture,  surrounded 
by  ornamental  trees,  shrubs,  flower  beds  and  a  beauti- 
ful landscape,  with  spacious,  artistically  decorated  inte- 
riors amply  stocked  with  comfortable  furniture,  is  not 
intended  for  prison  purposes.  Security  for  the  patients 
committed  to  his  care  is  not,  at  the  present  day,  the 
only  burden  of  the  superintendent's  responsibility. 

Public  sentiment  requires  that  insane  patients  in  hos- 
pitals shall,  as  far  as  possible,  be  restored  to  normal 
health,  and  that  all  patients,  both  acute  and  chronic, 
shall  be  provided  with  substantial  comforts,  shall  be 
protected  from  abuse  and  unnecessary  hardships,  and 
shall  enjoy  a  reasonable  degree  of  freedom.  It  is  well 
known  that  the  insane  were  subjected  to  shocking 
treatment  in  earlier  times,  and  no  doubt  insane  patients 
in  hospitals  set  apart  for  their  proper  care  and  treat- 
ment still  suffer  much  at  times  from  the  hands  of  those 
employed  to  nurse  and  watch  over  them.  Such  abuse 
of  the  insane  cannot  be  wholly  suppressed  until  the 

79 


So  CARE  OF  THE  INSANE 

old  system  of  coercion,  with  its  severe  discipline  and 
mechanical  appliances  to  substantiate  threats,  is  eradi- 
cated from  hospitals  for  the  insane,  and  practical  com- 
passion, with  gentle  arts  and  persuasive  measures,  is 
adopted  by  the  entire  management,  nurses  and  medical 
officials,  as  the  ruling  principle  in  managing  the  patients. 
The  management  of  the  insane  in  conformity  with 
the  Tuke  and  Conolly  practice  has  come  to  be  desig- 
nated as  the  ^'non-restraint"  system.  That  term  does 
not  signify  the  whole  scheme,  but  it  suggests  the  key 
to  this  humane  hospital  policy,  because  strait-jackets, 
wristlets,  bed  harnesses,  etc.,  are  the  obvious  and  tan- 
gible insignia  of  the  harsh,  repressive  methods  too  com- 
monly enforced  in  hospital  wards.  Then,  the  pacific, 
mollifying  arts  involved  in  properly  treating  the  insane 
cannot  be  successfully  inculcated  and  enforced  except 
where  mechanical  restraint  is  wholly  discarded.  There- 
fore, '' non-restraint"  has  properly  enough  been  accepted 
as  a  significant  word  s>Tnbol  for  the  highest  ethical 
development  of  hospital  management  in  the  care  of  the 
insane.  As  used  by  Conolly,  the  term  means  very 
much  more  than  the  absence  of  restraining  implements. 
The  essential  feature  of  this  method  is  the  underlying 
spirit  of  humane  endeavor  which,  when  intelligently 
directed,  will  obviate  the  apparent  necessity  for  using 
restraining  measures  by  happily  qualifying  all  the  rela- 


CARE  OF  THE  INSANE  8l 

tions  between  patients  and  employees  throughout  their 
entire  association. 

Strict  rules  admonishing  nurses  and  attendants  to 
avoid  abuse  of  patients,  abolishing  instruments  for  me- 
chanical restraint  and  increasing  the  wages  of  the  em- 
ployees are  commendable  steps  towards  improving  the 
condition  of  the  insane.  Yet  such  measures  will  fall 
short  of  protecting  troublesome,  unreasonable  patients 
in  hospitals  where  for  the  greater  part  of  the  time  they 
are  under  the  absolute  control  of  thoughtless,  dictatorial 
attendants  and  depend  for  their  comfort  upon  what 
abridged  rights  and  restricted  freedom  they  can  obtain 
from  employees.  Where  the  ward  management  of  tur- 
bulent patients  is  left  largely  to  the  discretion  of  attend- 
ants who  have  never  been  taught,  or  have  never  seen 
in  practice,  methods  of  controlling  the  insane  without 
threats,  and  without  mechanical  restraint,  the  unwise 
attendants  naturally  assume  that  patients  must  be  kept 
under  rigid  discipline,  and  held  in  such  a  state  of  sub- 
jugation that  they  will  promptly  obey  any  command 
given  them.  The  ignorant  and  undisciplined  inclina- 
tion of  such  employees  incites  them  to  bully  the  pa- 
tients, often  compelling  obedience  to  unnecessary  orders 
as  if  simply  to  test  their  docility.  And  some  of  the 
rougher  class  of  attendants  will  deliberately  attack  a 
new  patient  to  give  him  a  practical  demonstration  that 


82  CARE  OF  THE  INSANE 

pain  will  be  inflicted  and  many  privileges  will  be  sus- 
pended unless  he  passively  submits  to  such  tyrannical 
discipline.  One  motive  for  which  such  cruelties  are 
visited  upon  new  patients  in  hospitals  is  to  early  im- 
press them  with  a  fear  of  consequences  should  they 
report  to  medical  officials  instances  of  abuse  which 
they  may  suffer  or  may  see  inflicted  upon  other 
patients.  If  patients  who  have  been  badly  treated  by 
employees  suppress  the  facts  and  refuse  to  answer  ques- 
tions, a  reign  of  intimidation  is  the  most  probable  ex- 
planation for  their  attitude.  When  the  pitiless  attend- 
ant is  cautious  enough  to  fear  detection,  and  possible 
discharge,  if  it  becomes  known  that  he  assaulted  an 
insane  man,  he  can  usually  irritate  and  provoke  the 
patient  into  expressing  his  resentment  by  resisting  or 
striking  the  aggressor,  and  when  the  patient  has  actually 
struck  the  first  blow  his  fate  is  sealed.  Under  the  plea 
of  self-defense  the  attendant  can,  until  satisfied,  safely 
pommel  the  innocent  victim  of  his  malicious  motives. 

PubUc  opinion  is  occasionally  fanned  into  indignation 
by  published  reports  of  hospital  abuses.  At  such  times 
an  investigation  of  the  reported  death  or  serious  injury 
of  some  insane  patient  may  be  ordered  by  the  governor 
or  legislature.  As  an  outcome,  some  employee  may  be 
censured  and  discharged,  but  more  frequently  the  final 
report  will  minimize  the  outrage  because  the  situation, 


CARE  OF  THE  INSANE  83 

as  represented  by  interested  hospital  parties,  was  one 
of  great  peril  to  the  employee.  All  are  led  to  believe 
the  employee  was  in  personal  danger  and  simply  de- 
fended himself.  In  the  findings,  the  sad  results  of  such 
"hospital  accidents"  are  always  regretted,  but  are 
deemed  unavoidable  so  far  as  the  investigators  could 
judge.  Such  official  investigations  are  almost  always 
superficial,  and  the  verdict  serves  little  purpose  beyond 
softening  the  process  of  closing  the  incident.  The  com- 
mittees naturally  have  to  restrict  their  examination  to 
details  of  the  particular  encounter  which  ended  disas- 
trously. An  advocate  who  could  comprehend  the  whole 
affair  and  would  be  able  to  point  out  the  defects  of  such 
inquiries  seldom  appears  for  the  patient.  In  such  trials 
testimony  will  not  be  adduced  to  show  what  was  the 
probable  fact,  —  that  the  patient  was  a  long-suffering 
victim  of  irritating  taunts,  minor  abuses  and  repeated 
threats  which  finally  produced  an  insane  craving  for 
revenge,  —  and  no  one  will  volunteer  to  argue  the  pa- 
tient's right  to  defend  himself  when  he  had  cause  to 
believe  himself  in  danger  from  a  persistent  enemy.  As 
a  rule,  in  all  such  cases  the  "commission"  or  "commit- 
tee" consider  only  the  final  result  in  a  long  chain  of 
circumstances,  more  or  less  extended  as  to  time,  but  all 
leading  up  to  the  logical  catastrophe. 

Happily  such  hospital  conditions  are  exceptional,  al- 


84  CARE  OF  THE  INSANE' 

though  the  time  was  when  troublesome  patients  were 
very  generally  abused.  It  is  not  intimated  here  that 
such  methods  are  practiced  in  the  better-regulated  hos- 
pitals of  the  present  day.  But  without  doubt  a  minor 
phase  of  ward  despotism  does  exist,  not  infrequently,  in 
some  wards  of  most  hospitals  for  the  insane.  Too  often 
there  exists  a  condition  of  internal  affairs  where  attend- 
ants order  patients  about  in  rough  terms,  often  with 
profanity,  and  manifest  a  degree  of  impatience  that  ex- 
asperates nervous  invalids,  who  are  threatened  with 
removal  to  back  wards,  seclusion-rooms,  or  with  strait- 
jackets,  unless  they  respond  instantly  when  addressed 
by  the  ward  ''dictator."  The  great  majority  of  patients 
submit  to  such  treatment  —  some  meekly,  some  sul- 
lenly. But  occasionally  some  irritable  or  semi-demented 
person  will  continuously  ignore  the  commands  of  the 
churlish  overseer.  Then  follow  louder  and  more  terrible 
menaces,  until  the  baffled  petty  autocrat,  intent  upon 
maintaining  his  idea  of  discipHne,  strikes  or  seizes  the 
"rebellious  subject,"  who  may  then  unexpectedly  show 
much  fighting  ability,  and  as  a  consequence  some  one 
gets  injured,  usually  the  poor  patient.  The  order  given 
may  have  been  imnecessary  and  unreasonable,  but  once 
engaged  in  a  contest  to  demonstrate  his  autocracy,  the 
attendant,  if  a  novice,  will  be  anxious  chiefly  to  main- 
tain his  assumption  of  power  and  his  false  conception 


CARE  OF  THE  INSANE  85 

of  dignity,  failing  entirely  to  anticipate  the  ^'accidental" 
or  natural  consequences.  In  such  positions,  ''experi- 
enced," hardened  attendants  will  proceed  in  the  same 
way,  disregarding  all  chances  of  serious  results  to  the 
patient,  confident  that  they  can  mislead  officials  re- 
garding their  responsibility.  The  cases  where  patients 
resent  such  harsh,  imperious  discipKne  by  physical  re- 
sistance may  be  infrequent,  but  the  hardship  and  injus- 
tice incident  to  such  ward  management,  when  visited 
upon  large  groups  of  patients,  aggregates  an  immense 
sum  total  of  unhappiness  and  misery  which  might  be 
obviated  by  the  substitution  of  rational  methods  by 
which  to  control  insane  patients. 

And  yet,  the  attendants  who  inflict  such  discomfort 
and  misery  have  some  defense  for  their  conduct.  The 
hasty,  arbitrary  measures  enforced  by  the  average  state 
hospital  ward  attendant  may  represent  his  best  judg- 
ment and  be  the  measure  of  the  meager  or  erroneous 
instruction  he  has  received,  as  well  as  the  faulty  char- 
acter he  is  developing  for  himself  because  of  inadequate 
instruction  and  incompetent  guidance.  To  insure  the 
proper  treatment  of  the  insane  in  large  hospitals,  the 
individual  members  of  the  nursing  staff  should  have 
their  ideas  trained  to  understand  the  propriety  and  the 
importance  of  controlling  patients  by  gentle,  persuasive 
measures.     Their  sympathies  for  the  patient  should  be 


86  CARE  OF  THE  INSANE 

awakened  and  cultivated.  They  should  be  inducted 
into  the  practice  of  leading  patients  by  suggestion,  de- 
Hberation,  conscious  mental  power  and  the  advantages 
of  position.  They  should  take  professional  pride  in 
winning  mental  victories  over  the  turbulent  insane  and 
deplore  the  subjugation  of  confused  and  terrified  insane 
men  and  women  by  using  brute  force  and  strait-jackets. 
In  managing  insane  patients,  measures  calculated  to  in- 
spire confidence  should  be  adopted  when  possible;  but 
it  is  no  more  necessary  to  reveal  the  whole  truth  to  them, 
upon  all  occasions,  than  it  is  proper  to  keep  sane  patients 
informed  of  every  shade  of  opinion  concerning  their 
cases  which  may  be  entertained  by  their  medical  at- 
tendants. With  the  insane  it  is  important  to  engage 
their  attention  and  if  practicable  secure  their  coopera- 
tion. 

With  some  patients  the  simple  truth  will  serve  every 
purpose,  but  with  certain  others  it  will  not  succeed  and 
diplomatic  methods  must  be  called  into  requisition. 
Only  imsympathetic  physicians  will  at  all  times  dis- 
close their  conceptions  of  personal  facts  to  insane  pa- 
tients. Hope  and  confidence  in  the  insane  can  seldom 
be  developed  through  such  mistakenly  honest  inten- 
tions. In  truth,  such  brutal  frankness  could  be  ex- 
pected from  those  only  who  discover  nothing  but  good 
in  using  strait-jackets.     It  may  be  true   that  hospital 


CARE  OF  THE  INSANE  87 

physicians  often  criticize  those  who  use  deception  in 
committing  patients  to  hospitals  for  the  insane,  and  it 
is  seldom  wise  or  necessary  to  do  so;  but  there  are  in- 
stances when  painful  and  even  serious  consequences  to 
the  patient  and  his  friends  may  be  obviated  by  resorting 
to  stratagem  and  diplomacy. 

When  persons  fully  recover  from  insanity  they  will 
show  no  resentment  against  old  friends  who  in  the  try- 
ing process  of  incarceration  obscured  the  truth.  How- 
ever captious  respecting  the  conduct  of  patients'  friends 
in  this  respect  hospital  physicians  may  be,  it  is  safe  to 
assume  that  those  with  experience  seldom  go  through 
their  own  wards  addressing  and  replying  to  the  patients 
with  literal  candor.  Of  course  no  self-respecting  physi- 
cian treats  his  patients  having  mental  disorder  by  falsi- 
fying. Yet  he  should  vary  his  style  of  communication 
and  exercise  more  or  less  reservation  to  pertinently  meet 
the  complex  mental  conditions  with  which  he  has  to 
deal.  He  should  guard  his  tongue  and  not  tell  too 
much  truth.  He  should  often  mask  his  opinions  and 
be  prepared  to  veto  patients'  whims,  baffle  their  inten- 
tions and  evade  their  direct  questions  without  defi- 
nitely committing  himself  or  arousing  their  antagonism. 
To  command  the  situation  at  all  times,  he  will  have 
frequently  to  insinuate  and  suggest  rather  than  affirm, 
employ  figurative  speech  freely  instead  of  giving  cate- 


88  CARE  OF  THE  INSANE 

gorical  answers,  and  project  captivating  schemes  befit- 
ting the  humor  of  the  patient  or  his  mental  peculiarities. 
Many  patients,  incoherent  or  demented,  have  no 
power  of  discrimination,  while  others  may  be  exceed- 
ingly penetrating  and  subtle.  Hallucinations  and  delu- 
sions should  be  kindly  corrected,  again  and  again,  by 
cogent,  logical  explanations.  Not  that  truth  and  reason 
will  certainly  dissolve  such  errors  of  sense  and  judg- 
ment, but  they  do  have  weight  in  some  cases. 

Sufferers  from  mental  depression  need  mental  stim- 
ulus, and  to  them  attractive  and  interesting  subjects 
should  be  so  charmingly  presented  as  to  evoke  thoughts 
along  new  channels.  Restless,  overactive  cases  should 
have  provided  a  safe  outlet  for  their  excessive  kinetic 
energy,  which  cannot  be  thwarted  but  can  be  modified 
and  diverted. 

Manic  cases  with  an  exaggerated  ego  and  prolific 
activities,  playfully  rather  than  viciously  inclined,  can 
always  be  induced  to  expend  their  augmented  mental 
and  physical  force  in  some  harmless  way.  Such  cases 
usually  puzzle  the  physicians,  and  worry  the  employees, 
as  they  become  naturally  rebellious  under  strict  disci- 
pHne.  But  they  are  always  tractable  when  properly 
handled.  For  them  some  unusual  and  interesting  line 
of  conduct  should  be  devised,  —  something  congruous 
with    their   prevailing   conceit.     They   are   easily   be- 


CARE  OF  THE  INSANE  89 

witched  with  a  notion  of  doing  something  fantastic  or 
most  exceptional,  and  under  a  giddy  exterior  often  re- 
tain a  semi-correct  sense  of  propriety  and  a  whimsical 
code  of  honor.^ 

Such  cases  cannot  be  expected  to  conform  to  a  rigid 
system  of  ward  discipline.  The  hospital  management 
ought  to  be  sufficiently  elastic  and  reasonable  to  pro- 
vide exceptions  and  variations  adapted  to  the  individual 
requirements  of  these  exacting  patients.  This  class  of 
patients  is  never  large  and  the  acute  condition  is  seldom 
prolonged.  They  generally  recover  in  time  and  recol- 
lect all  that  transpired  during  their  mental  excitement. 
The  author  of  "A  Mind  That  Found  Itself"  most  graph- 
ically describes  the  mental  conditions  of  such  a  case.^ 

''Non-restraint"  in  its  literal,  narrow  sense  may  be 
made  the  rule  of  an  institution  without  bettering  the 
treatment  of  the  patients.  There  are  other  processes 
more  painful  and  more  dangerous  than  wearing  the 

1  See  illustrative  case  reported  in  the  Appendix. 

2  "A  Mind  That  Found  Itself,"  an  autobiography  by  Clifford  W. 
Beers,  published  by  Longmans,  Green  &  Company,  443  Fourth  Ave- 
nue, New  York  City.  In  this  book  the  author  tells  of  his  experi- 
ences while  a  patient  in  sundry  private  and  public  hospitals  for  the 
insane  during  the  years  1900-1903,  and  suggests  a  plan  for  a  national 
movement  in  mental  hygiene,  and  for  the  improvement  of  conditions 
among  the  insane.  This  plan  has  since  been  put  into  effect  under  the 
auspices  of  the  National  Committee  for  Mental  Hygiene,  which  has 
come  into  existence  as  a  result  of  the  publication  of  "A  Mind  That 
Found  Itself." 


90  CARE  OF  THE  INSANE 

camisole,  which  can  be  employed  by  tyrannical  attend- 
ants to  frighten  and  intimidate  defenseless  patients. 

Doubtless  patients  will  occasionally  present  critical  con- 
ditions which  seem  to  necessitate  mechanical  restraint, 
and  when  the  use  of  such  appliances  would  result 
in  no  injury,  mental  or  physical,  to  that  particular  pa- 
tient. Could  the  treatment  of  such  a  case  be  entirely 
dissociated  from  all  other  cases  in  the  minds  of  the 
physicians  and  nurses,  the  use  of  straps  and  jackets 
might  be  regarded  as  unobjectionable.  But  in  institu- 
tions for  the  custody  of  the  insane,  the  general  welfare 
of  the  whole  body  of  inmates  depends  very  much  upon 
the  morale  of  the  nursing  staff,  and  with  its  members 
the  demoraUzing  effects  of  making  exceptions  to  the 
^^non-restraint"  rule  are  so  pernicious  and  wide-reach- 
ing that  yielding  to  the  use  of  mechanical  restraint  with 
occasional  patients  would  sacrifice  the  best  interests  of 
a  multitude  of  other  cases  having  equal  claims  upon  the 
management  for  protection  from  imnecessary  restraint 
and  ignominy.  The  superintendent  who  imagines  he  is 
controlling  the  use  of  mechanical  restraint  in  the  hospital 
where  he  directs  affairs,  when  he  reserves  to  himself 
the  power  of  deciding  whether  mechanical  restraint 
can  be  used  in  any  given  case,  does  not  see  himself  as 
others  see  him.  Even  the  nurses  understand  the  situa- 
tion better  than   he.     They  clearly  realize   that   the 


CARE  OF  THE   INSANE  9 1 

judgment  of  such  officials  on  this  point  of  restraint  is 
always  an  inspiration  from  themselves. 

He  receives  by  messenger,  or  through  the  telephone, 
a  report  from  nurses  that  some  patient  is  desperately 
suicidal  or  dangerously  maniacal,  with  a  request  that 
permission  for  restraint  be  granted.  He  dare  not  decide 
against  their  evident  wishes  under  such  circumstances. 
The  nurses  may  assume  to  be  physically  incapable  of 
further  effort.  The  executive  chief  is  mentally  and 
morally  helpless  when  thus  appealed  to  unless  he  has 
previously  established  the  "non-restraint"  treatment  as 
the  imdeviating  working  practice  in  his  hospital. 

Occasionally  a  medical  superintendent  who  believes 
in  the  use  of  mechanical  restraint,  for  exceptionally 
trying  cases  at  least,  will  cite  an  affray  with  an  insane 
patient,  stating  conditions  which  actually  confronted 
the  attendants,  and  request  a  solution  of  the  situation 
from  some  "non-restraint''  advocate.  Such  superinten- 
dents misapprehend  the  "non-restraint"  theory.  It  is 
possible  that  nothing  short  of  some  form  of  restraint  or 
seclusion  would  instantly  meet  all  the  requirements  of 
the  case  as  described.  The  correct  and  the  better 
method  had  been  too  long  neglected.  Rational  treat- 
ment should  have  been  applied  to  the  case  reported 
weeks,  months,  possibly  years,  before  such  a  violent 
culmination  of  threats  and  neglect  by  incompetent  em- 


92  CARE  OF  THE  INSANE 

ployees  occurred.  The  cure  for  such  troubles  consists 
in  educating  nurses  and  attendants  to  become  true 
nurses,  with  a  thoroughly  humane  conception  of  their 
duties.  They  must  be  willing  to  follow  helpful  sugges- 
tions and  apply  correct  principles  in  efforts  to  influence 
rather  than  coerce  the  insane  over  whom  they  have 
charge.  While  the  superintendent  who  asks  in  sincer- 
ity how  nurses  are  to  extricate  themselves  from  impend- 
ing conflicts  with  patients  without  using  force  may  feel 
justified  in  his  attitude  with  the  answer  he  receives,  by 
his  question  he  unwittingly  exposes  to  the  experienced 
"non-restraint"  patron  the  prevaiHng  lack  of  proper 
system  of  ward  management  in  his  own  institution. 

The  superintendent  who  seriously  desires  to  avoid 
the  use  of  mechanical  restraint  will  have  not  only  to 
forbid  and  aboHsh  it,  but  to  keep  a  careful  watch  over 
the  nurses  and  their  dealings  with  patients,  especially 
in  those  wards  where  new  and  troublesome  cases  are 
located.  The  number  of  patients  Hkely  to  get  into 
trouble  with  the  nurses  is  not  large  in  any  one  well-con- 
ducted hospital,  and  concerning  the  treatment  of  these 
the  superintendent  can  and  should  exhibit  constant 
solicitude.  He  should  personally  investigate  every  in- 
stance of  violence  between  nurses  and  patients  and  keep 
a  record  of  his  findings.  This  can  be  done  by  requiring 
all  employees  to  report  in  writing,  and  without  delay, 


CARE  OF  THE  INSANE  93 

every  instance  of  accident  to  or  trouble  with  a  patient. 
Special  blank  cards  for  this  purpose  should  be  in  the 
hands  of  all  nurses,  to  be  filled  out  in  every  case  of  fric- 
tion with  a  patient.^  These  cards  the  superintendent 
should  file  under  the  patient's  name  after  having  made 
a  personal  investigation  of  the  affair  reported.  This 
means  additional  burdens  of  care,  labor  and  responsi- 
bility for  him,  but  the  best  interests  of  the  patients  re- 
quire it  and  the  interested  public  should  expect  nothing 
else.  Unless  the  superintendent  takes  an  active  part 
in  organizing  and  conducting  a  "non-restraint"  cru- 
sade, the  work  will  be  superficial  and  spasmodic.  Nurses 
will  lack  continuous  initiative  unless  stimulated  by  his 
interest  in  the  general  scope  and  many  details  of  this 
policy.  He  will  need  to  utilize  the  services  of  deputy 
assistants  and  supervisors  who  understand  his  views  and 
who  can  be  trusted  to  act  with  intelligence  and  loyalty. 
It  is  imperative  that  all  wards,  in  which  are  placed 
patients  likely  to  give  trouble,  should  be  under  the 
charge  of  head  nurses  in  every  way  competent  to  man- 
age patients  without  restraint  and  who  are  willing  to 
teach  their  ward  helpers  the  art,  its  principle  and  the 
details  of  its  application.  Such  head  nurses  must  them- 
selves scrupulously  observe  all  the  requirements,  or  they 
will  weaken  their  influence  and  control  over  their  ap- 
prentices. Irresponsible  employees  could  be  quickly  dis- 
^  See  Card  Index  in  Appendix 


94  CARE  OF  THE  INSANE 

posed  of  and  the  abuse  of  patients  could  be  effectually 
checked  if  only  a  number  of  such  head  nurses  in  each 
hospital  placed  at  strategic  points  would  faithfully  re- 
port each  instance  of  infraction  or  neglect  of  duty.  In 
most  hospitals  for  the  insane  there  prevails  among  nurses 
a  fictitious  sense  of  honor  which  favors  employees  and 
does  not  protect  or  vindicate  the  patients. 

The  superintendent  should  in  all  possible  ways  adopt 
plans  which  will  facilitate  the  successful  working  of 
the  "non-restraint ''  policy.  The  overcrowding  of  wards, 
especially  those  appropriate  for  the  care  of  noisy  and 
fractious  patients,  should  be  avoided.  He  may  not  be 
able  to  regulate  admissions  to  the  institution,  but  over- 
crowding is  such  a  serious  interference  with  skillful 
nursing  he  should  register  his  protest  when  conditions 
prevent  the  best  work. 

The  proper  classification  of  those  patients  likely  to 
cause  trouble  is  a  great  aid  to  the  *^ non-restraint"  meth- 
ods. Not  that  all  disorderly  inclined  patients  should  be 
herded  in  back  wards,  for  irritable  patients  react  upon 
each  other  and  should  be  frequently  changed  from  ward 
to  ward  so  they  may  engage  in  forming  new  compan- 
ionships and  avoid  tiresome  associations.  In  making 
such  changes,  personal  antipathies  between  patients, 
or  patients  and  certain  nurses,  should  receive  consid- 
eration.   But  nurses  should  not  be  permitted  to  force 


CARE  OF  THE  INSANE  95 

such  changes  where  it  is  evident  they  are  chiefly  con- 
cerned to  rid  themselves  of  the  care  of  troublesome 
patients.  Unless  some  patients  are  transferred  from  a 
noisy  to  a  quiet  ward  before  the  excitement  has  wholly 
subsided,  their  convalescence  may  be  retarded.  Such 
a  transfer  from  back  to  front  ward,  and  then  returning, 
repeated  several  times,  is  often  the  correct  way  to  stimu- 
late them  to  exercise  self-control.  Seclusion  may  be 
necessary  at  times,  but  it  should  be  remembered  that 
prolonged  seclusion  is  bad  practice.  The  shorter  the 
period  of  seclusion,  as  a  rule,  the  better  the  effect  upon 
the  disturbed  patient.  Noisy,  destructive  patients  are 
seldom  improved  by  solitary  confinement.  Exercise  out 
of  doors  to  the  point  of  physical  fatigue,  with  a  compe- 
tent guard  of  nurses,  is  a  much  better  form  of  isolation 
from  other  patients,  and  a  practical  way  of  treating 
such  cases.  Ample  facilities  for  prolonged  warm  baths 
must  be  provided.  When  the  temperature  of  the  water 
is  maintained  a  degree  or  two  below  blood  heat  there  is 
little  risk  of  heart  failure. 

Persistent  destruction  of  clothing  is  fostered,  not  cured, 
by  the  use  of  ill-fitting  canvas  dresses.  Better  supply 
material  having  bright  colors  and  striking  figures  — 
something  that  will  appeal  to  what  vestige  of  pride  may 
exist  —  that  will  attract  the  eye  and,  possibly,  alter  the 
purpose  of  the  victim  of  destructive  habits. 


96  CARE  OF  THE  INSANE 

Daily  out-of-door  exercise  for  all  able-bodied  patients 
should  be  insisted  upon  whenever  the  weather  is  suit- 
able, and  all  patients  who  are  physically  able  to  work 
should  be  urged  to  engage  in  some  form  of  labor,  at 
least  a  part  of  each  day.  Let  those  who  object  to 
physical  exertion  accompany  those  willing  to  labor,  even 
if  at  first  they  simply  stand  around  and  watch  the  busy 
workers.  Under  such  circumstances,  the  influence  of  a 
good  example  is  suggestive,  frequently  inducing  idlers 
to  participate  in  useful  employment.  Patients  who 
work  faithfully  and  diligently  should  receive  some  re- 
ward. Occasionally,  a  small  sum  of  money  regularly 
paid  as  a  gratuity  will  secure  their  good-will  and  stim- 
ulate their  exertions.  Special  diet,  extra  clothing,  to- 
bacco, occasional  excursions,  may  be  profitably  granted 
as  inducements  to  render  efficient  and  continued  service. 
Compelling  patients  to  work  should  be  strictly  forbid- 
den, as  serious  conflicts  have  resulted  frequently  through 
attempts  on  the  part  of  attendants  or  nurses  to  force 
patients  to  serve  them  at  ward  duty  or  in  performing 
some  disagreeable  task.  Inducing  patients  to  work  or 
to  conduct  themselves  properly  through  gifts,  rewards 
or  favors  is  a  prominent  and  legitimate  feature  in  the 
"non-restraint"  system.  Head  nurses  over  all  wards 
where  restive  and  seemingly  obstinate  patients  dwell 
should  be  Hberally  suppHed  at  all  times  with  extra  food, 


CARE  OF  THE  INSANE  97 

fruit,  candy,  pictures,  etc.,  for  use  in  distracting  the 
attention  of  excited  patients  and  as  a  ready  means  by 
which  to  estabhsh  friendly  relations  with  patients  who 
are  suspicious. 

It  may  be  proper  to  keep  medicines  in  each  ward 
under  the  care  of  the  head  nurse,  but  dangerous  drugs 
—  those  with  which  suicide  could  be  effected  —  had 
better  be  elsewhere  or  securely  placed.  Medicine  in- 
tended to  produce  quiet  and  sleep  should  be  kept  in 
the  administration  drug  room.  The  more  free  the  use 
of  hypnotics  with  the  insane,  the  more  noisy  they  are 
at  night  and  the  greater  the  demand  for  more  hyp- 
notic medication.  By  the  use  of  such  drugs  a  tempo- 
rary, quieting  effect  may  be  produced,  but  the  reaction 
which  usually  follows  intensifies  the  original  condition, 
and  patients  thus  indulged  become  impatient  for  a 
repetition.  Hypodermic  medication  of  this  class  should 
seldom  be  employed,  as  a  drug  habit  is  easily  contracted 
and  tenaciously  held.  Hypodermic  needles  and  tablets 
should  not  be  entrusted  to  the  nurses  lest  some  patient 
some  day  get  a  hypnotic  injection  that  was  not  ordered 
by  the  physician. 

Nervous,  restive  patients  should  be  assigned  to  large, 
roomy  wards  whenever  possible,  so  they  may  freely 
roam  about,  greet  new  acquaintances  before  they  tire 
of  enforced  companionship  and  vent  some  explosive  en- 


98  CARE  OF  THE  INSANE] 

ergy  while  aimlessly  tramping  about  the  long  wards. 
Cramped  accommodations  and  restricted  movements  are 
decidedly  irritating  to  the  insane  and  should  be  avoided 
except  when  exhaustion  is  Hkely  to  supervene  upon  too 
prolonged  physical  exertion.  Noisy,  talkative  persons 
should  be  taken  into  the  fields  and  woods  to  correct 
their  impleasant  habits,  not  consigned  to  out-of-the-way 
dark  rooms.  The  more  close  the  restrictions,  as  when 
in  a  cell  or  strait-jacket,  the  more  intense  the  irritation, 
fear  and  suffering;  consequently  the  more  persistent 
the  noise  and  the  louder  the  shouting.  As  a  result  of 
natural  laws,  it  is  to  be  expected  that  painful  mental 
tension  incident  to  extreme  limitations  of  space  or  mo- 
tion will  gradually  relax,  to  be  succeeded  by  a  sense  of 
relief  and  quiet  as  the  restrictions  are  mitigated  and 
gradually  transformed  into  a  state  of  freedom. 

The  relation  of  instinctive  mental  conditions  to  vary- 
ing degrees  of  space  ought  to  be  considered  in  planning  ac- 
commodations and  treatment  for  the  insane.  A  greater 
nimiber  of  nurses  should  be  employed  when  mechanical 
restraint  is  abolished,  as  the  duties  and  actual  labor 
with  excitable  and  depressed  patients  are  increased  un- 
der the  ''non-restraint"  methods.  In  large  wards,  ac- 
commodating acute  or  intractable  cases,  nurses  should 
be  constantly  posted  at  several  points  about  the  room 
in  order  to  suppress  quarrels  among  patients  and  to 


CARE  OF  THE  INSANE  99 

detect  violent  conduct  in  its  incipient  stage.  Patients 
with  suicidal  tendencies  should  be  assembled  in  a  special 
ward  or  dormitory  where  continual  watch  can  be  kept 
over  the  whole  company,  both  day  and  night.  Their 
every  movement  should  be  under  trained  observation. 
Practically  all  departments  for  patients  should  be  kept 
under  strict  watch  at  night.  Night  supervisors  and 
night  watchmen  should  be  employed  and  competent 
nurses  should  be  kept  both  day  and  night  in  all 
wards  occupied  by  untrustworthy  patients,  so  the  old 
practice  of  locking  patients  in  single  rooms  at  night  can 
be  discontinued.  Watched  dormitories  are  more  suit- 
able sleeping  places  for  the  majority  of  patients  than 
ordinary  single  rooms.  There  cannot  be  too  much 
watchfulness  in  hospitals  for  the  insane.  No  power 
on  earth  so  effectually  controls  the  conduct  of  men  as 
human  vision,  and  so  the  eye  of  a  qualified  nurse  aided 
by  a  prudent  tongue  can  control  nearly  all  insane  pa- 
tients without  any  physical  exertion. 

There  are  good  reasons  why  it  is  advisable  to  open 
hospitals  for  the  insane  to  the  public  often  and  fully. 
When  public  inspection  or  visiting  days  recur  frequently, 
the  nurses  are  stimulated  to  keep  their  wards  in  a  pre- 
sentable condition,  as  they  know  the  general  appearance 
of  the  halls  and  rooms,  as  well  as  the  patients'  cloth- 
ing, will  fall  under  critical  observation.     This  constant 


lOO  CARE  OF  THE   INSANE 

anticipation  keeps  both  nurses  and  patients  more 
active  and  more  cheerful  than  would  the  dead  level  of 
hospital  routine.  The  patients'  hopes  are  awakened 
and  their  spirits  are  stimulated  by  coming  into  close 
contact  with  people  of  the  outside  world.  When  pub- 
lic visiting  days  occur  twice  weekly,  as  in  some  institu- 
tions, and  a  large  number  of  strangers  pass  through  the 
wards  each  open  day,  the  patients  become  so  accustomed 
to  the  spectacle  that  they  regard  the  visitors  with  com- 
paratively Httle  curiosity,  maintaining  a  good  degree  of 
dignity  and  seldom  exhibit  undue  excitement.  With 
frequent  repetitions,  the  sight  of  outsiders  becomes  a 
simple  matter  of  course  and  the  patients  appear  self- 
possessed  and  natural,  while  patients  who  seldom  meet 
strangers  will  flock  about  a  visitor  in  their  wards,  many 
talking  at  the  same  time,  each  intent  upon  securing 
recognition  or  exacting  some  promise. 

Properly  conducted  hospitals  for  the  insane  no  longer 
afford  such  grotesque  and  shocking  spectacles  as,  ac- 
cording to  Pepys  and  Hogarth,  were  on  exhibition  in 
old  '' Bedlam."  No  doubt  many  persons  at  the  present 
day  are  prompted  to  visit  hospitals  for  the  insane  out 
of  curiosity,  but  the  tables  are  practically  turned  in 
hospitals  where  frequent  ward  visiting  is  the  rule:  the 
parading  visitors  provide  the  exhibition.  Their  evident 
timidity  and  unconscious  stupidity  often  interest  the 


CARE  OF  THE   INSANE  lOI 

patients,  who  quietly  note  and  enjoy  the  passing  show, 
which  they  may  subsequently  criticize  or  analyze  with 
jest  and  merriment.  Besides,  it  is  a  needed  and  valu- 
able object-lesson  to  the  public.  The  world  at  large 
still  entertains  too  many  exaggerated  and  erroneous 
opinions  concerning  the  internal  conditions  of  such 
institutions.  When  the  visitors  enter  the  better-class 
hospitals  and  walk  through  ward  after  ward  without 
detecting  anything  remarkable,  it  is  a  revelation  to 
them.  They  note  the  large,  pleasant  Hving  rooms,  well- 
furnished  tidy  sleeping  rooms  and  attractive  dining  halls, 
with  appointments,  in  many  respects,  superior  to  those 
provided  in  the  patients'  homes.  They  observe  the 
scrupulous  cleanhness  which  generally  prevails,  the  pic- 
tures and  ornaments  displayed  in  most  wards,  and  are 
especially  impressed  with  the  natural  appearance  and 
good  behavior  of  the  patients.  In  this  way  they  re- 
ceive impressions  and  carry  away  convictions  which  go 
far  towards  correcting  the  prejudicial  traditions  con- 
cerning such  institutions,  which  have  been  treasured 
and  often  repeated  in  the  very  circles  represented  by 
such  visitors. 

Friends  of  patients  err  when  they  deprecate  such  pub- 
Kcity  for  the  insane  confined  in  hospitals.  Few  of  the 
insane  are  sensitive  respecting  their  condition,  and  the 
majority  pine   for   friendly   associations.     False  pride 


I02  CARE  OF  THE  INSANE 

should  not  be  permitted  to  immure  them  so  completely 
as  to  cut  them  off  from  sight  and  sound  of  sane  Hfe,  and 
permit  them  to  see  only  the  faces  of  their  fellow  patients 
and  custodians.  The  greater  the  publicity  of  the  man- 
agement, the  less  opportunity  there  is  for  injustice  to 
the  patients.  As  a  rule,  visits  from  strangers  have  less 
objectionable  results  upon  the  patients'  mental  condi- 
tion than  frequent  visits  from  near  relatives.  Rela- 
tives and  friends  cannot  understand  why  their  visits  to 
the  mentally  sick  should  produce  harmful  results,  and 
yet  such  is  the  frequent  outcome  of  premature  or  too 
frequent  visits  by  injudicious  kindred  and  friends. 
Convalescing  patients  are  likely  to  be  set  back  by  a  re- 
vival of  emotions  linked  with  family  associations,  and 
many  chronic  cases  are  kept  in  a  state  of  unrest  and 
smothering  rebellion  through  unwise  sympathy  and  ill- 
expressed  friendship  proffered  by  timid  kindred. 

Hospital  life  is  necessarily  monotonous,  and  liberal 
diversion  is  the  rational  antidote  with  which  to  counter- 
act its  bad  effects.  Amusements  varying  in  character 
should  be  provided  at  short  and  regular  intervals  for  the 
entertainment  and  mental  relaxation  of  the  patients. 
Anything  which  agreeably  enlists  and  engrosses  the 
attention  fulfills  the  requirements.  Music  and  dancing 
can  always  be  depended  upon  to  produce  satisfactory 
results. 


CARE  OF  THE   INSANE  103 

A  congregate  dining  room  can  be  utilized  to  add  vari- 
ety to  the  patients'  daily  life,  to  change  the  drift  of 
morbid  thoughts  and  inclinations,  and  to  introduce  nor- 
mal conditions  as  fully  as  possible  into  hospital  meth- 
ods. Both  male  and  female  patients  should  be  accom- 
modated in  the  same  dining  room,  their  tables  being 
separated  by  a  wide  passageway  through  the  center  of 
the  hall.  No  kind  of  food  should  be  placed  upon  the 
tables  until  all  have  been  seated.  Food  can  then  be 
distributed  from  rubber-tired  cars  in  the  center  aisle,  or 
be  served  from  sideboards  against  the  walls,  by  selected 
patients  acting  as  waiters,  one  waiter  to  each  table. 
The  meals  should  be  so  planned  that  the  food  can  be 
served  in  a  number  of  courses,  the  more  table  etiquette 
the  better,  allowing  fully  one  hour  for  dinner  and  forty- 
five  minutes  for  breakfast  and  supper.  In  such  dining 
rooms  haste  is  objectionable,  and  five  hundred  to  fifteen 
hundred  patients  can  be  managed  and  be  properly  fed 
with  ease  and  quietness.  The  time  patients  thus  spend 
at  table  and  consume  coming  from  and  returning  to 
their  wards  will  amount  to  at  least  three  hours  a  day. 
An  orchestra  should  be  employed  to  furnish  music 
all  the  time  patients  are  present,  morning,  noon  and 
night.  Only  those  who  have  had  experience  with  such 
meal  arrangement  can  appreciate  the  power  this  method 
of  meal  serving  has  towards  promoting  the  self-respect 


I04  CARE  OF  THE  INSANE 

of  the  individual  patients  and  tranquilizing  ward  condi- 
tions throughout  the  whole  hospital.  The  aim  and  pur- 
pose of  such  dining-room  practice  should  be  to  cultivate 
good  table  manners,  to  occupy  the  patients'  time  agree- 
ably, to  increase  the  self-respect  and  self-control  of  the 
patients  by  adopting  as  fully  as  possible  the  dining- 
room  customs  of  large  aggregations  of  normal  people. 
Incidentally,  it  allows  ample  time  for  quiet  meals  to  be 
served  attendants  and  nurses,  usually  in  one  section  of 
the  same  room.  It  also  removes  from  the  living  wards 
objectionable  odors  and  annoying  housekeeping  duties, 
and,  last  to  be  considered,  it  is  decidedly  economical  as 
regards  cost  for  food,  waste  and  service. 

The  music  is  an  important,  probably  an  essential,  fea- 
ture. Many  patients  listen  with  pleasure,  and  it  affects 
the  outward  manifestations  of  all  present.  Without 
music  there  would  be  more  noise,  more  loud  talking,  and 
some  patients  would  find  it  difficult  to  repress  an  inclina- 
tion to  lecture  the  officials  or  others  present,  and  make 
statements  leading  to  rejoinders  and  disputes.  With 
attractively  arranged  tables  surrounded  by  plants  and 
flowers,  and  with  neatly  attired  patients,  entertained  by 
good  music,  little  more  is  required  to  make  the  congre- 
gate dining  room  the  acknowledged  social  center  of  the 
establishment,  from  which  will  emanate  good  influences 
to  tone  and  characterize  the  whole  institution. 


NURSING  STAFF. 

In  hospitals  for  the  insane  the  patients  have  to  de- 
pend chiefly  upon  the  nurses  for  sane  companionship, 
as  the  medical  officers  can  of  necessity  devote  but  httle 
time  to  individual  cases.  Therefore,  the  general  intel- 
ligence and  natural  disposition  of  the  nurses,  supple- 
mented by  their  conceptions  of  duty  and  knowledge  of 
nursing  the  insane,  determine,  in  a  large  measure,  the 
domestic  and  social  atmosphere  by  which  the  patients 
are  surrounded  during  their  whole  hospital  residence. 

All  superintendents  appreciate  the  importance  of  se- 
lecting employees  with  especial  care  as  regards  their 
qualifications  for  the  trying  positions  offered  them,  but 
the  fact  that  preliminary  arrangements  with  hospital 
employees  have  in  most  cases  to  be  negotiated  by  corre- 
spondence renders  it  impossible  to  cull  from  the  Hst  of 
appHcants  only  those  who  can  be  depended  upon  to 
make  satisfactory  nurses.  Objectionable  candidates  may 
be  occasionally  barred  by  requiring  in  advance  a  condi- 
tional contract,  duly  signed,  in  which  the  applicant 
agrees  to  observe  all  the  rules  and  regulations  and  to 
obey  all  orders,  written  or  verbal,  issued  by  the  hos- 
pital authorities. 

105 


Io6  CARE  OF  THE  INSANE 

It  is  to  be  regretted  that  ambitious  young  women 
with  a  high-school  or  collegiate  education  do  not  more 
generally  become  interested  in  this  special  work,  which 
is  well  compensated  and  which  offers  numerous  oppor- 
tunities for  promotion.  Women  superintendents  of  gen- 
eral hospitals  and  training  schools  for  nurses  are  always 
in  demand  at  liberal  salaries. 

While  some  of  the  duties  in  state  hospitals  are  ad- 
mittedly unpleasant,  there  are  compensations  other  than 
the  financial  consideration  to  interest  and  repay  the 
faithful  worker  in  such  hospital  wards.  Under  present 
conditions  and  the  ordinary  understanding  as  to  what 
such  positions  offer,  this  service  attracts  young  country 
people  more  than  other  classes  of  wage  earners,  as  the 
wages  paid  are  higher  than  in  agricultural  or  domestic 
pursuits  and  where  only  more  laborious  situations  are 
open  to  them.  Beginners  in  stores  and  factories  usually 
receive  less  remuneration  for  labor  than  the  hospitals 
pay.  Hospitals  have  to  depend  largely  upon  much  in- 
competent, inexperienced  help,  since  nursing  the  insane 
seems  to  present  little  attraction  for  other  classes  of 
wage  earners. 

Then,  of  the  many  who  engage  in  hospital  ward  work, 
few  remain  in  the  service  longer  than  six  months,  and 
the  ranks  of  the  nursing  staff  are  continuously  recruited, 
almost  wholly  from  country  districts.     But  how  to  se- 


CARE  OF  THE   INSANE  107 


cure  a  better  class  of  nurses  to  care  for  and  manage  the 
insane  is  not  simply  a  question  of  advancing  the  scale  of 
wages,  although  more  thoroughly  competent  graduates 
from  the  training  schools  should  each  year  be  induced 
to  remain  in  the  service  by  a  liberal  increase  of  salary. 
Higher  initial  wages  would  accompKsh  very  little,  as 
few  candidates  who  could  command  equal  wages  by 
teaching  or  clerking  would  willingly  submit  to  the  dis- 
cipline necessary  to  fit  them  for  successful  nurses  in 
hospitals  for  the  insane.  If  increasing  hospital  wages 
did  secure  employees  with  a  higher  grade  of  education 
and  better  general  information,  such  broader  mental 
experience  in  itself  fits  no  one  for  ward  service  in  hos- 
pitals for  the  insane.  Men  and  women  thoroughly  com- 
petent to  care  for  and  manage  the  insane  are  never  born 
with  perfect  endowment  for  that  peculiar  service,  nor 
can  such  qualifications  be  developed  outside  hospital 
wards. 

When  inexperienced  employees  enter  upon  ward  duties 
they  are  usually  suppKed  with  a  rule  book  which  con- 
tains many  fundamental  laws  intended  to  regulate  their 
general  conduct  towards  the  patients.  Concerning  the 
treatment  of  patients  who  give  trouble,  certain  prohibi- 
tions will  be  recorded  in  these  booklets,  but  such  man- 
uals give  scant  information  as  to  the  correct  principles 
of  nursing  those  suffering  from  mental  disorder.     Indeed, 


I08  CARE  OF  THE  INSANE 

in  many  training  schools  little  attention  is  given  to  this 
special  and  most  important  branch  of  mental  nursing. 
Pupils  are  expected  to  acquire  all  that  is  necessary  in 
this  direction  by  ward  experience.  The  consequence  is 
that  in  most  hospitals  for  the  insane  the  majority  of 
attendants  and  nurses  are  poorly  prepared  for  the  diffi- 
cult and  perplexing  tasks  they  are  occasionally  com- 
pelled to  undertake. 

Young  men  and  women,  with  an  education  no  better 
than  the  country  common  school  affords,  with  such 
mental  and  moral  discipline  only  as  may  be  derived  from 
isolated  family  life  in  rural  abodes,  and  with  no  practical 
experience  in  adjusting  themselves  to  a  social  environ- 
ment where  the  ordinary  rights  and  privileges  of  each 
individual  may  conflict  in  some  manner  or  degree,  are 
placed  in  wards  crowded  with  insane  patients  and  are 
assigned  duties  the  discharge  of  which  would  at  times 
tax  the  mind  of  a  mature  philosopher  and  the  heart  of 
a  veteran  in  philanthropic  work.  It  is  not  surprising 
that  they  frequently  make  a  sad  failure  of  the  under- 
taking. In  earlier  hospital  days,  some  attendants,  by 
long  experience  and  with  good  counsel,  became  pro- 
ficient workers  with  insane  patients  in  hospitals,  be- 
cause of  their  inborn  capacity  and  love  for  the  work. 
But  now  hospital  demands  for  employees  are  so  great 
that  the  necessary  number  of  willing  and  apt  pupils 


CARE  OF  THE  INSANE  IO9 

must  be  obtained  from  any  possible  source  and  then  be 
carefully  taught  the  theory  and  practice  of  mental 
nursing,  if  better  results  are  to  be  required  of  hospital 
management. 

The  ordinary  nursing  instruction  given  in  the  aver- 
age nurses'  training  school  is  useful  knowledge  and  an 
excellent  foundation  for  practical  experience  in  high- 
class  work.  But  as  a  preparation  for  proper  work  in 
hospitals  for  the  insane,  pupils  must  be  drilled  upon  the 
proper  attitude  the  nurse  should  assume  tow^ards  the 
insane  upon  all  occasions.  They  must  be  taught  much 
that  is  scarcely  considered  in  the  nursing  books.  They 
must  be  induced  to  school  themselves  in  habits  of  self- 
control.  They  must  be  made  to  comprehend  that  phi- 
losophy which  teaches  how  to  conquer  the  perversities 
of  human  nature  by  indirect  means  rather  than  by  pro- 
hibition. They  must  become  proficient  in  overcoming 
evil  notions  by  the  substitution  of  good  ideas  in  the 
minds  of  their  patients.  They  must  by  practice  acquire 
skill  in  a  difficult  art,  —  the  art  of  leading  by  clever  sug- 
gestions obstinate  human  beings  whom  no  hving  person 
could  drive.  Nurses  commencing  this  form  of  hospital 
work  should  be  early  impressed  with  the  difficulties  and 
trials  before  them,  as  well  as  the  ample  rewards  awaiting 
all  who  finish  the  course  and  graduate  after  two  or  three 
years  of  study  and  ward  work.    Their  personal  ambition 


no  CARE  OF  THE  INSANE 

and  enthusiasm  regarding  this  work  should  be  cultivated 
through  repeated  graphic  representations  of  the  advan- 
tages —  educational  and  characterwise  —  which  nurses 
may  expect  to  derive  by  following  after  high  ideals  in 
nursing  and  managing  insane  patients. 

The  unfolding  and  interpretation  of  this  art  of  nurs- 
ing instruction  cannot  be  entrusted  solely  to  supervisors 
and  principals  of  training  schools.  The  executive  chief 
of  the  whole  estabhshment,  the  superintendent,  must 
interest  himself  deeply  and  work  industriously  if  he 
hopes  to  develop  in  his  hospital  wards  the  right  hospital 
spirit  and  the  better  ways  of  nursing. 

If  humane  methods  are  to  prevail  in  hospitals  for  the 
insane,  nurses  must  be  allowed  to  take  some  risks  with 
bad  patients,  and  this  they  cannot  be  expected  to  do 
without  the  approval  of  the  superintendent.  They  must 
act  for  him  in  such  work,  and  he  must  be  ever  ready  to 
support  and  defend  all  subordinates  who  conscientiously 
and  intelligently  endeavor  to  manage  the  insane  with- 
out restraint  or  other  harsh  measures. 

The  outlines  of  a  desperate  case  and  some  of  the 
methods  employed  to  change  the  patient's  mental  habit 
will  suggest  the  dangers  involved  and  the  necessity 
for  deviating  from  hospital  routine  in  caring  for  such 
cases. 

A  seventeen-year-old  girl  from  the  West  Indies  drifted 


CARE  OF  THE  INSANE  III 

into  a  state  institution.  She  had  occasional  epileptic 
attacks  with  some  hysterical  indications,  and  suicidal 
impulses  persistently  recurred.  While  the  convulsions 
were  infrequent,  for  days  at  a  time  she  would  appear 
morose,  nervous  and  irritable.  During  such  spells  she 
sometimes  made  vicious  attacks  upon  nurses  and  unless 
closely  watched  would  endeavor  to  strangle  herself  by 
twisting  articles  of  clothing,  twine,  or  strips  of  cloth 
about  her  neck.  She  often  packed  rags,  paper  and 
small  articles  in  her  mouth,  nose  and  throat,  and  so 
stealthy  were  her  movements  that  nurses  in  the  room 
with  her  sometimes  became  aware  of  her  suicidal  at- 
tempt  only  when  her  face  became  dusky  as  the  result  of 
obstructed  respiration. 

This  case  gave  the  doctors  and  nurses  an  endless 
amount  of  trouble  and  anxiety.  They  feared  the  girl 
would  kill  herself  unless  her  hands  were  restrained  by 
mechanical  appHances.  But  she  was  so  unusually  supple 
she  could  squirm  out  of  any  ordinary  restraining  appa- 
ratus. Yet  in  time  they  devised  a  special  bed  harness 
from  which  she  could  not  escape.  After  several  months 
of  such  confinement  she  was  removed,  by  official  orders, 
to  another  institution  where  the  '^ non-restraint''  system 
of  treating  patients  had  been  adopted. 

The  nurse  who  conducted  the  transfer  said  the  change 
was  made  because  at  the  first  institution  they  ^^  could  do 


112  CARE  OF  THE  INSANE 

nothing  with  the  patient."  When  asked  if  mechanical 
restraint  had  been  employed,  she  replied,  ''Yes,  she  has 
been  allowed  out  of  it  only  two  hours  each  day."  In  the 
second  institution  this  patient  remained  three  or  more 
years,  being  at  no  time  subjected  to  mechanical  or  chem- 
ical restraint.  Such  a  record  was  possible  only  as  the 
result  of  concerted  work  by  the  superintendent,  assist- 
ant physicians  and  the  nurses.  Naturally  the  most 
difficult  part  fell  to  the  lot  of  the  nurses.  They  were 
given  to  understand  that  the  case  was  certain  to  test 
''non-restraint"  nursing,  and  their  best  efforts  were 
enhsted.  The  nurse  in  charge  became  devotedly  in- 
terested, and  her  personal  attentions  to  the  case  repre- 
sented vigilance  personified.  She  possessed  unusual  tact, 
was  fertile  in  devising  expedients,  and  fathomed  human 
motives  with  facility.  She  quickly  discerned  that  van- 
ity was  the  patient's  distinctive  characteristic,  and  this 
furnished  a  clue  to  the  proper  method  of  procedure  cal- 
culated to  regenerate  this  uneducated  but  cunning  epi- 
leptic. The  girl  was  praised  and  flattered  upon  all  pos- 
sible occasions,  and  constant  efforts  were  made  to  give 
her  pleasure  and  encourage  her  self-esteem.  All  con- 
spired in  a  laudable  spirit  to  give  her  special  attention. 
She  was  provided  with  pretty  dresses,  decorated  with 
ribbons,  and  scented  with  perfume.  When  nurses  went 
out  for  a  day  they  usually  brought  her  some  present 


CARE  OF  THE  INSANE  113 

such  as  candy,  fruit,  cheap  rings,  beads,  etc.  They 
secured  special  articles  of  food  for  her  and  invited  her 
to  share  their  extra  lunches  and  little  feasts,  and  all 
made  a  pet  of  her.  The  ward  physicians  aided  in  these 
plans  by  giving  her  special  prominence  and  compliment- 
ing her  good  appearance.  They  would  accept  from  her 
reports  concerning  other  patients  which  had  been  sug- 
gested by  the  nurses. 

To  encourage  her  self-esteem,  nurses  often  requested 
her  to  watch  some  troublesome  patient,  and  found  they 
could  depend  upon  her  good  conduct  and  fidelity  when 
her  usefulness  was  thus  magnified.  They  gave  her  the 
use  of  a  drawer  with  a  private  lock  in  the  linen  room, 
and  permitted  her  to  wear  the  key  on  a  tape  around  her 
neck.  They  often  requested  her  to  keep  their  small, 
personal  belongings,  and  never  was  such  confidence  mis- 
placed, while  she  would  pilfer  from  nurses  in  other 
wards  without  hesitation. 

She  was  frequently  taken  out  of  doors  for  special 
walks,  to  the  storeroom  for  ward  supplies  or  personal 
knickknacks  and  to  the  greenhouse  for  flowers.  As  her 
general  conduct  improved,  she  was  taken  to  the  congre- 
gate dining  room  for  meals  and  to  the  weekly  dance. 
On  such  occasions  she  was  decked  out  with  especial 
care,  and  often  wore  by  permission  a  nurse's  watch  or 
other  jewelry.     To  arouse  her  from  her  morbid  brood- 


114  CARE  OF  THE  INSANE 

ings,  the  nurse  sometimes  gave  her  the  ward  key  and 
requested  her  to  visit  other  wards  to  convey  a  message 
or  receive  a  report.  This  was  done  at  times  when  the 
nurse  had  so  little  confidence  in  the  patient  that  a  pre- 
vious arrangement  was  made  with  the  other  nurse  to 
put  night  locks  on  outside  doors  and  to  watch  the 
patient  carefully.  Gradually  under  such  influences  her 
despondent  periods  became  less  frequent  and  less  pro- 
longed, and  in  time  she  actually  enjoyed  Hmited  parole 
outside  the  hospital  wards. 

After  several  years  spent  under  such  friendly  and 
stimulating  associations,  she  was  again  officially  trans- 
ferred to  another  institution. 

Room  for  acute  cases  was  urgently  needed  in  the 
hospital,  and,  mindful  of  her  epileptic  infirmity,  she  was 
this  time  taken  to  an  asylum  for  chronic  cases.  But 
the  asylum  management  continued  the  methods  em- 
ployed in  institution  No.  2.  She  was  constantly  under 
kind,  judicious  watch.  She  was  provided  with  toys, 
amusing  games,  attractive  pictures,  bright-colored  orna- 
ments, etc.  As  a  rule  she  responded  to  such  pleasant 
surroundings  in  a  satisfactory  manner,  but  on  several 
occasions  while  in  the  last  institution  she  almost  suc- 
ceeded in  committing  suicide.  Eventually,  however, 
her  improvement  was  so  pronounced  that  the  state 
authorities  deemed  it  prudent  and  justifiable  to  deport 


CARE  OF  THE  INSANE]  II5 

her  to  her  native  island,  where  her  brother  lived  and 
was  to  take  charge  of  her. 

The  special  attention  given  this  case  was  costly  to 
the  state  and  burdensome  upon  officials  and  nurses, 
and  yet  it  was  money  well  expended  and  personal  efforts 
well  directed.  Of  the  many  nurses  who  freely  gave,  to 
this  afflicted  child,  mind  and  heart  service  which  riches 
cannot  command,  none  ever  regretted  her  contribution 
or  failed  to  reap  her  reward.  The  moral  effect  of  such 
a  triumph  over  serious  mental  conditions  was  well  worth 
the  state's  financial  investment  for  the  good  it  accom- 
pHshed  in  the  two  institutions  which  faithfully  endeav- 
ored to  discharge  their  moral  obligations  to  a  thankless 
alien. 

.  Officers  and  employees  must  be  impressed  with  the 
paramount  importance  of  gaining  the  patient's  confi- 
dence and  good-will  through  kind  measures  and  gentle 
treatment,  at  and  from  the  time  they  enter  the  hospital. 
Beginning  in  the  right  way  with  new  patients  is  all- 
important,  but  unfortunately  for  nurses  as  well  as  pa- 
tients current  rumors  of  hospital  iniquities  and  popu- 
lar prejudice  against  employees  in  hospitals  for  the 
insane  are  so  widely  spread  and  so  deeply  seated  that 
very  many  patients  enter  such  institutions  with  a  keen 
apprehension  of  ill  usage  and  punishments  to  come. 
The  science  of  mental  nursing  emphasizes  the  impor- 


Il6  CARE  OF  THE  INSANE 

tance  of  neutralizing  as  quickly  as  possible  the  baneful 
effects  of  such  painful  anticipations.     Arguments  with 
distracted  individuals  will  not  dispel  such  enthralHng 
vagaries.     Substitution  is   the  only  effectual  remedy. 
The  patient's  mind  must  become  preoccupied  with  ideas 
of  an  opposite  character.     He  must  be  favorably  im- 
pressed by  persistent  kindness.     Agreeable  surroundings 
and  reassuring  observations  must  serve  to  crowd  his 
dismal  forebodings  into  the  background  of  his  thought 
and  memory.     Unless  this  rational,  humane  method  be 
adopted,  the  patient  will  retain  his  horrifying  convic- 
tions and  possibly  reenforce  them  by  unfortunate  expe- 
riences.    Under  such  regrettable  conditions,  the  patient 
may  naturally  come  to  view  the  ordinary  conduct  of 
the  nurses  in  the  light  of  his  preconceptions.    Atten- 
tions to  himself,  prompted  by  kind  motives,  may  be 
misunderstood  and  be  resented.     Gentle  attempts  to 
aid  him  in  undressing  and  dressing,  in  bathing  or  serv- 
ing food,  will  be  magnified  and  distorted  by  his  dis- 
ordered imagination  and  faulty  reasoning  into  assaults 
and  homicidal  designs.     Such  vagaries  he  will  firmly 
believe,  and  his  conduct  will  accord  mth  them.     If  he 
does  not  completely  recover,  he  will  always  retain  such 
convictions   and   subsequently  relate   them   to   friends 
and  others  as  facts.     Who  could  reasonably  expect  to 
sooth  and  quiet  a  distracted  person,  or  reassure  a  wor- 


CARE  OF  THE  INSANE  117 

lying  and  suspicious  insane  man,  by  sharp  commands, 
hustling  movements,  and  threats  of  a  dark  room  or 
the  strait-jacket?  And  yet  such  are  the  means  which 
naturally  seem  proper  for  the  purpose  to  the  nurses 
and  laymen  who  are  ignorant  concerning  better  meth- 
ods, or  who  feel  they  possess  an  agency  in  mechanical 
restraint  with  which  the  obdurate  patient  can  be  effec- 
tually subdued.  It  is  this  conscious  command  of  effec- 
tual physical  power  held  in  reserve  that  destroys  the 
making  of  a  good  nurse  in  hospitals  when  straps  and 
strait- jackets  are  allowed.  When  a  nurse  is  certain 
that  a  patient  can  be  humiliated  or  rendered  helpless  at 
her  pleasure,  by  the  application  of  ties,  straps  or  canvas 
jackets,  she  will  not  long  tolerate  unkind  and  abusive 
words  from  the  patient.  She  will  not  tax  her  strength 
and  mental  power  in  attempts  to  calm  the  patient's 
excitement  with  soothing  words.  She  will  not  suffi- 
ciently exert  herself  to  divert  the  patient's  attention. 
Neither  will  she  bestow  upon  the  confused  or  distressed 
patient  genuine  sympathy,  the  indulgence  and  cultiva- 
tion of  which  serve  important  functions  in  improving 
the  character  of  the  nurse  while  it  is  often  effectual  in 
awakening  the  better  sense  of  the  patient.  When  em- 
ployees make  frequent  use  of  strait-jackets  on  patients 
that  are  noisy,  destructive  to  clothing,  or  violent,  they 
sacrifice  their  finer  sensibilities,  their  normal  compassion 


Il8  CARE  OF  THE  INSANE 

for  pain  and  mental  torture  is  rapidly  blunted,  while 
their  acquired  indifference  to  the  humiliation  and  pun- 
ishment they  inflict  upon  irresponsible,  helpless  human 
beings  brutalizes  their  nature  and  perverts  their  char- 
acter. Ex-employees  have  been  known  to  boast  of  their 
cruel,  fiendish  treatment  of  weak  but  noisy  insane 
patients  twenty-five  years  after  they  left  the  hospital 
service.  Mechanical  restraint  of  the  insane  is  so  an- 
tagonistic to  the  spirit  or  principle  which  must  pervade 
all  rational  schemes  for  controlling  the  insane  that  it 
should  be  totally  abolished,  or  teaching  ^'non-restraint'' 
methods  to  nurses  will  avail  Httle.  The  possibility  of 
restraint  lodged  in  the  mind  of  the  nurse  smothers 
serious  efforts  to  influence  the  patient  by  the  charm  of 
pity  and  the  power  of  the  intellect. 

It  depends  almost  wholly  upon  the  superintendent 
of  each  institution  whether  mechanical  restraint  is 
used  in  his  hospital  wards.  The  stand  he  takes  upon 
this  important  question  of  management  will  be  under- 
stood by  all  his  subordinates  and  influence  them  in 
their  dealings  with  the  patients.  If  he  is  determined 
that  restraint  shall  not  be  used,  he  will  caution  the 
whole  hospital  force  of  workers  upon  every  convenient 
occasion.  He  will  show  his  appreciation  when  they 
have  managed  cases  well  and  repeat  optimistic  sugges- 
tions concerning  their  success  if  they  ever  waver  in 


CARE  OF  THE  INSANE  II9 

their  convictions.  He  should  continually  remind  oj0&- 
cers  and  nurses  that  the  secret  of  ^^non-restraint"  — 
if  there  be  any  mystery  regarding  the  question  — 
consists  in  preventing  or  avoiding  situations  where 
restraint  might  be  thought  necessary  by  those  who  ap- 
prove its  use.  Those  who  argue  that  insane  patients 
will  take  advantage  of  the  milder  methods  of  treat- 
ment and  that  an  absence  of  strict  discipline  will  re- 
sult —  a  condition  which  spells  riot  in  their  school  — 
little  appreciate  the  power  that  well-poised,  properly 
taught,  expert  nurses  can  exercise  over  the  insane  by 
mental  suggestion,  calm  persuasion  and  innocent  arti- 
fice. Ward  disorders  can  be  more  easily  prevented  by 
the  judicious  words  of  a  quiet,  self-possessed,  gentle- 
toned  nurse  than  by  the  threats  and  stormy  commands 
of  a  ferocious  keeper.  A  loud-talking  patient  can  be 
quieted  often  by  a  polite  request  whispered  in  the  ear. 
Because  women  nurses  exhibit  less  show  of  force,  avoid 
threats  and  stern  commands,  they  manage  patients  in 
the  male  wards  with  less  irritation  and  fewer  outbreaks 
than  occur  when  male  attendants  are  in  charge.  For 
this  reason  female  nurses  should  be  employed  in  the 
male  wards  of  hospitals  as  soon  as  a  sufficient  number 
of  well-instructed,  sensible  women  nurses  can  be  ob- 
tained. Slender,  light-weight  girls  have  managed  wards 
for  excitable  female  patients  quite  as  easily  as  women  of 


I20  CARE  OF  THE  INSANE 

greater  weight  and  strength  because  the  smaller  women 
had  acquired  the  real  art  of  managing  insane  patients. 
To  be  eminently  successful  in  this  work,  a  nurse  ought  to 
be  endowed  with  some  capacity  for  offhand  romancing. 
Persons  who  cannot  conceive  of  a  well-behaved,  fairly 
quiet  ward  of  insane  patients,  without  mentally  exalt- 
ing the  idea  of  discipline,  used  in  its  repressive  sense, 
evidently  are  uninstructed  or  mistaken  as  to  the  char- 
acter and  quaHty  of  measures  most  efficient  in  control- 
ling the  insane.  The  medical  superintendent  of  every 
hospital  for  the  insane  in  the  United  States  would  no 
doubt  gladly  aboHsh  mechanical  restraint  if  he  thought 
his  employees  could  manage  the  patients  without  it. 
But  employees  never  will  control  the  insane  by  the 
"non-restraint''  practice  until  they  are  taught  the  proper 
methods  and  have  been  compelled  to  adopt  them,  not 
only  in  the  letter  but  in  the  spirit,  which  is  far-reaching. 
Discharging  or  even  imprisoning  a  few  attendants  guilty 
of  serious  assaults  will  not  end  asylum  abuses.  Inves- 
tigations by  legislative  committees  cannot  set  up  and 
supervise  the  only  competent  agency  which  will  reduce 
to  a  minimum  the  hardships  and  wrongs  needlessly  in- 
flicted upon  the  insane  in  hospitals.  The  superintend- 
ent is  the  only  person  in  the  institution  who  possesses 
sufficient  authority  to  adopt  the  "non-restraint"  system 
of  management  and  to  enforce  its  observance.     To  sue- 


CARE  OF  THE  INSANE  121 

ceed,  he  will  have  to  spend  much  time  over  the  details 
of  difficult  cases,  as  he  cannot  afford  to  have  the  nurses 
fail,  and  must  therefore  convince  them  of  their  inherent 
ability  to  succeed,  and  encourage  perseverance.  Nat- 
urally, some  will  succeed  much  better  than  others,  and 
those  who  are  doomed  to  failure  through  unfavorable 
temperament  or  inadequate  power  of  application  will 
voluntarily  resign  early  in  their  experience.  To  keep 
some  nurses  from  carelessness  or  mistakes  will  require 
dehberate  watching  and  frequent  aid  with  suggestion. 
When  the  superintendent  appreciates  their  success  in 
controlling  irritable  and  violent  cases  and  bestows  mer- 
ited commendation  as  they  improve  with  practice,  the 
nurses  are  greatly  helped  and  stimulated  to  do  even 
better  work.  They  will  often  depend  upon  his  sym- 
pathy and  encouragement  to  withstand  the  prolonged 
strain  which  some  hard  cases  will  cause. 

Dr.  Conolly,  who  succeeded  in  managing  the  insane 
in  accordance  with  '^ non-restraint"  ideas,  —  something 
which  so  many  other  superintendents  have  deemed  im- 
possible, —  devoted  a  surprising  amount  of  time  and 
personal  attention  to  each  trying  case  in  his  hospital. 
He  made  repeated  visits  at  night,  as  well  as  by  day,  to 
wards  where  troublesome  patients  were  worrying  the 
nurses.  He  thoroughly  informed  himself  of  the  diffi- 
culties to  be  overcome  in  case  after  case,  and  of  the 


122  CARE  OF  THE  INSANE 

ability  of  properly  trained  nurses  to  master  all  possible 
situations,  before  he  published  his  sweeping  conclusion, 
viz.,  that  '^all  insane  patients  can  be  managed  without 
mechanical  restraint"  and  that  all  superintendents  who 
desire  to  conduct  hospitals  for  the  insane  on  the  *' non- 
restraint"  plan  ''will  succeed  if  they  are  in  earnest." 
Results  of  so  much  consequence,  both  to  patients  and 
nurses,  should  not  be  sacrificed  because  officials  lack 
earnest  endeavor  to  pursue  the  methods  by  which  alone 
they  may  be  secured. 

To  redeem  the  ward  management  of  hospitals  for  the 
insane  from  the  sway  of  untaught,  rough  and  unsym- 
pathetic attendants  means  physical  comforts,  mental 
cheer  and  hopefulness  to  afflicted  multitudes  who  are 
entitled  to  our  compassion.  To  improve  the  under- 
standing and  enrich  the  character  of  the  great  body  of 
nurses  in  these  special  institutions  is  a  worthy  object 
and  one  of  great  promise.  Primarily,  the  occupation  of 
hospital  nursing  should  be  given  an  improved  standing. 
Higher  conceptions  of  its  dignity  and  its  educational 
possibilities  should  be  held  by  officials  and  by  them  in- 
stilled into  the  minds  of  the  ward  workers.  Ideals  of 
devotion,  self-sacrifice  and  humane  service  should  be 
recounted  for  their  benefit.  Then  the  educational,  sci- 
entific and  humanizing  acquisitions  which  will  redound 
to  the  faithful  student  and  the  patient  worker  in  this 


CARE  OF  THE  INSANE  1 23 

field  should  be  more  widely  understood.  They  should 
be  taught  to  regard  ward  work  in  the  light  of  laboratory 
experience  in  solving  interesting  and  important  prob- 
lems relating  to  science  and  humanity.  Associated 
with  this  work  there  are  some  repugnant  duties,  some 
trying  situations,  but  such  objectionable  features  of  the 
service  can  and  should  be  minimized  by  contrasting 
them  with  the  personal  gains  and  the  unlimited  benefits 
which  they  bestow  upon  patients  when  the  nurses  are 
wisely  and  conscientiously  discharging  their  hospital 
duties.  If  one  expects  to  have  nurses  hold  their  posi- 
tions with, such  ideals  in  mind,  he  must  extol  the  ad- 
vantages they  will  receive  by  pursuing  such  a  course  in 
training  until  they  can  read  into  humble  duties  the 
promise  of  higher  things.  There  is  much  that  can  be 
adduced  to  prove  that  the  submissive,  painstaking  nurse 
will  be  well  repaid  for  devoted  work.  Her  command  of 
the  EngKsh  language  will  be  improved  by  mastering 
lessons  in  text-books  on  nursing  and  by  writing  reports 
and  examination  papers.  She  will  become  well  informed 
upon  the  laws  of  hygiene,  learn  how  infectious  diseases 
spread  and  are  suppressed,  understand  the  significance 
of  pulse  and  temperature  variations,  —  all  practical  mat- 
ters, the  knowledge  of  which  she  can  utilize  to  her  per- 
sonal advantage  through  her  life;  or  she  can  turn  them 
to  account  by  taking  up  private  nursing  as  a  career. 


124  CARE.  OF  THE  INSANE 

Graduate  nurses,  trained  in  hospitals  for  the  insane 
where  the  correct  "non-restraint"  policy  is  enforced, 
meet  with  the  greatest  success  in  private  nursing.  Be- 
fore entering  the  field  for  family  nursing,  it  is  advisable 
for  these  graduates  to  take  a  supplemental  course  in 
some  general  or  special  hospital.  But,  with  or  without 
extra  or  special  instruction  and  experience,  their  self- 
command,  their  readiness  to  meet  the  unexpected,  their 
tactful  methods  with  all  persons,  are  accomplishments 
which  they  acquired  in  the  hospital  for  insane  and 
which  will  continue  in  evidence  and  will  prove  their 
best  recommendation.  After  years  spent  with  insane 
persons  who  have  been  held  in  check  or  stimulated  into 
action  and  have  been  again  and  again  turned  from  hasty 
or  destructive  purposes  by  her  calm  persistence,  inven- 
tive genius  and  mental  alertness,  the  nurse  has  devel- 
oped her  latent  mental  capacity  and  force  of  character, 
and  if  normally  well  endowed  will  be  able  to  adjust  her- 
self to  the  temper  of  ordinary  people  or  the  caprice  of 
sick  folks  without  effort  or  delay.  Nervous,  peevish 
invalids  are  not  puzzles  to  her.  If  the  mood  of  the 
patient  changes,  she  alters  her  mode  of  approach.  If 
the  patient  is  depressed  and  disconsolate,  she  avoids 
recalling  matters  concerning  which  the  patient  is  sensi- 
tive by  ignoring  such  subjects  and  promptly  finding  an 
opening  for  some  interesting  and  optimistic  suggestions. 


CARE  OF  THE  INSANE  1 25 

If  the  patient  is  obsessed  by  some  depressing  reflection, 
the  properly  educated  nurse  eschews  the  words  *'Do 
not,"  and  all  requests  expressed  by  a  negative  phrase, 
because  such  phrases  revive  the  unfortunate  mental 
association.  She  quietly  interests  the  patient's  atten- 
tion in  an  opposite  direction.  She  should  never  be  at  a 
loss  for  expedients  suitable  to  serve  her  purpose.  Such 
expert  comprehension  of  the  moods  peculiar  to  invalids 
can  be  acquired  nowhere  else  so  quickly  and  so  thor- 
oughly as  in  the  wards  of  a  hospital  for  the  insane  where 
mechanical  restraint  is  never  used  or  thought  of.  This 
consummate  tact  is  the  natural  outgrowth  of  mental 
nursing  when  the  nurse  is  deprived  of  all  means  by 
which  to  inflict  penalties  or  punishments,  and  where  she 
and  the  patients  about  her  know  that  threats  are  idle 
expressions. 

Dispossessed  thus  of  coercive  power,  imder  all  circum- 
stances she  must  retain  her  presence  of  mind.  She  will 
have  to  appeal  to  friendly  feehngs,  be  able  to  interpret 
intentions  rapidly  and  reach  positive  conclusions  as 
quickly.  She  will  also  have  to  depend  upon  novel  and 
fascinating  schemes  invented  at  a  moment's  notice  to 
fit  the  requirements.  She  must  remain  calm  when  others 
are  excited,  must  control  her  temper  when  tantalized, 
insulted  or  defied,  and  must  accustom  herself  even  to 
receive  blows  without  showing  resentment.     In  this  work 


126  CARE  OF  THE  INSANE 

the  nurse  can  be  aided  by  general  rules  only,  because  it 
is  impossible  to  anticipate  the  exact  conditions  that  will 
enter  into  any  perplexing  situation.  No  two  patients 
are  wholly  alike,  and  the  mental  aspect  of  each  patient 
varies  with  time  and  circumstances.  Then,  the  per- 
sonality of  the  nurses  will  differ,  each  from  the  others, 
and  all  these  variations  in  temperament  and  temper  call 
for  modifications  in  methods  of  approaching  patients. 
Hence  it  is  that  only  practice  in  such  surroundings 
insures  perfection  in  the  art.  To  have  acquired  such 
an  art  means  that  the  nurse  who  has  mastered  it  has 
brought  into  working  order  all  the  mental  resources 
with  which  she  was  endowed.  She  will  then  be  fitted  to 
measure  her  ability  with  that  of  any  person  with  whom 
she  may  come  into  association  —  sane  as  well  as  in- 
sane. It  is  doubtful  if  any  other  established  educa- 
tional course  will,  in  the  same  length  of  time,  better 
develop  the  practical  capacity  of  a  student  nurse,  or 
better  fit  her  to  cope  with  the  struggle  incident  to  her 
lifework. 

The  same  ''non-restraint"  kind  of  mental  nursing  is 
excellent  practice  for  character  building.  It  induces 
habits  of  self-discipline  by  necessitating  deliberation, 
self-restraint,  serenity  under  provocation,  and  the  ha- 
bitual practice  of  good  deeds  in  return  for  indifference 
and  possibly  evil  intentions.     To  maintain  their  influ- 


CARE  OF  THE  INSANE  127 

ence  over  the  patients,  nurses  must  be  invariably  kind. 
When  a  nurse  considers  the  misfortune  of  the  insane 
through  compassionate  eyes,  her  humane  sentiments 
are  cultivated.  Scrutinizing  mental  wrecks,  resulting 
from  degeneracy,  dissipation  and  disease,  as  nurses  must, 
for  some  germ  of  manhood  that  may  respond  to  the 
sunny  influence  of  kindness,  sympathy  and  good  counsel, 
enables  them  to  appreciate  the  better  side  of  humanity 
in  general.  Pitying  those  who  suffer  from  painful  delu- 
sions as  truly  as  though  the  cause  for  the  anguish  ex- 
perienced were  genuine  develops  depth  of  feeling  and 
emotions  regulated  by  intelligence. 

Giving  cups  of  water  to  thirsty  but  helpless  patients 
and  ministering  to  their  many  necessities  with  kind 
attention  and  a  cheerful  spirit  reveals  to  the  true  nurse 
the  one  certain  method  by  which  personal  happiness  can 
always  be  realized. 

Such  are  the  constant  opportunities  for  exercising 
benevolent  sentiments  confronting  every  nurse  in  hos- 
pitals for  the  insane. 

If  this  moral  and  ethical  phase  of  nursing  were  pre- 
sented in  the  right  way  and  sufficiently  often,  the  major- 
ity of  nurses  would  respond  favorably.  From  this  point 
of  view,  nursing  in  hospitals  for  the  insane  calls  for  high- 
class  work,  approaching  in  many  respects  the  heroic. 

The  superficial  impressions  of   nursing   the  insane 


128  CARE  OF  THE  INSANE 

which  freedom-loving  youths  and  maidens  usually  ob- 
tain by  entering  upon  the  preliminary  courses  in  train- 
ing schools  are  often  repugnant,  and  few  who  enter  the 
classes  continue  the  work  long  enough  to  render  intelli- 
gent service  or  to  discover  in  its  pursuit  as  an  occupation 
much  that  is  agreeable  or  satisfactory. 

Those  who  remain  in  the  training  school  long  enough 
to  graduate  generally  do  so  because  of  the  financial 
considerations  only,  and  feel  little  inclination  to  con- 
tinue such  exacting  duties.  If  prevalent  ideas  concern- 
ing this  important  field  of  work  could  be  radically 
changed  for  the  better,  if  devotion  to  the  service  of 
mental  nursing  in  hospitals  commanded  the  interest  and 
consideration  it  is  entitled  to  receive  when  undertaken 
with  intelligence  in  the  right  spirit,  there  might  be  re- 
tained permanently  in  hospitals  for  the  insane  an  ample 
corps  of  serious-minded,  faithful  nurses  who  would  act 
in  obedience  to  the  high  sentiments  and  unselfish  mo- 
tives befitting  this  ennobhng  occupation.  Can  such 
desirable  ends  be  consummated?  Can  devoted  nurses 
be  so  attracted  to  this  worthy  cause  that  they  will 
intelligently  undertake  a  lifework  in  behalf  of  those, 
many  of  whom  are  incapable  of  appreciation,  and  who 
often  resist  or  blindly  attack  their  best  friends  and  bene- 
factors? Certainly  not  through  coercive  measures  or 
restrictive  legislation.    Not  until  promptings  to  render 


CARE  OF  THE  INSANE  1 29 

unselfish  service  to  insane  patients  spring  from  the 
convictions  and  high  sense  of  duty  of  the  individual 
nurses.  They  cannot  be  frightened  or  effectually  driven 
into  the  mental  state  that  insures  the  right  conduct 
towards  patients  any  more  than  nurses  can  by  force 
compel  patients  to  effectively  improve  their  manners. 

How  to  improve  and  elevate  the  grade  of  insane 
hospital  nursing  is  a  problem  involving  the  action  and 
reaction  of  human  nature  and  the  force  of  cultivated 
ideals. 

The  work  should  be  presented  to  nurses  in  attrac- 
tive, interesting  terms  comporting  with  high  social  and 
professional  standards.  Its  importance,  its  dignity,  its 
self-sacrifice  and  also  its  compensations  should  be  ap- 
preciated and  acknowledged  in  words  and  deeds  by 
both  hospital  officials  and  an  interested  public.  Nurses 
should  be  allured  to  this  special  field  of  devotion  by  a 
desire  to  share  in  the  inherent  glory  which  results  from 
serving  thankless  insane  patients  for  the  cause  of  hu- 
manity. But  this  is  a  very  practical  age  and  few  young 
persons  are  willing  to  sacrifice  a  life  of  commercial  and 
social  opportunity  even  for  so  high  and  humane  a  calhng. 

As  a  rule,  good  nurses  cannot  be  expected  to  ignore  or 
reject  more  tempting  emoluments  offered  them  for  nurs- 
ing the  sane  sick  in  private  families  or  for  some  less 
exacting  business  occupation.     Teaching  the  act  of  nurs- 


130  CARE  OF  THE  INSANE 

ing  the  insane  in  hospitals  and  inculcating  the  ethics 
involved  to  small  classes  in  scattered  institutions  are 
laborious  duties  devolving  upon  hospital  officials;  and 
when  the  comparatively  meager  results  are  considered 
in  connection  with  the  broader  field  of  hospital  require- 
ments, the  necessity  for  educational  centers  with  a 
broader  foundation  and  a  wider  reaching  influence,  en- 
thusiastically engaged  in  this  work,  is  clearly  appre- 
hended. 

For  this  end,  state  commissions  would  act  wisely  in 
establishing  schools  for  high-class  instruction  in  nursing 
the  insane. 

Some  religious  or  benevolent  order  that  would  duly 
heed  the  scientific  and  practical  aspects  of  the  work 
would,  if  engaged  in  this  line  of  service,  accomplish  great 
good.  If  a  national  guild  or  non-religious  society  of 
nurses  engaged  in  caring  for  insane  patients  could  be 
formed  and  maintained  with  a  chapter  in  each  hospital, 
officered  and  conducted  by  the  nurses  themselves,  hav- 
ing a  simple  ritual  and  the  literature  necessary  to  keep 
before  them  high  ideals  of  nursing  and  calculated  to 
foster  enthusiasm  for  the  work,  it  is  possible  that  the 
right  ideas  and  the  right  spirit  could  be  more  widely 
and  more  rapidly  disseminated.  Such  an  organization 
should  have  a  central  bureau  of  administration,  with 
proper  officers  to  regulate  its  work  and  agents  to  super- 


CARE   OF  THE  INSANE  131 

vise  the  work  of  the  chapters.  Graded  ranks  should  be 
established,  and  promotions  from  rank  to  rank  should 
depend  upon  personal  character,  length  of  service  and 
acquired  proficiency  in  the  art  of  managing  insane 
patients.  A  system  of  marking  for  rewards  and  pro- 
motion should  be  entrusted  to  the  chapters,  but  all 
reports  should  require  the  indorsement  of  the  local  hos- 
pital officials  before  fihng  for  subsequent  use.  To  be 
entirely  successful,  such  a  central  organization  should  be 
started  with  a  substantial  foundation,  having  sufficient 
funds  to  manage  affairs,  to  provide  insurance  for  loss 
of  time  in  sickness,  an  old-age  pension,  and  medals  or 
gratuities  for  special  meritorious  acts.  If  a  monthly 
compensation  could  be  granted  members  of  the  higher 
circles,  it  would  promote  ambition  to  rise  in  the  order. 
A  scheme  of  this  character  would  in  no  way  antagonize 
the  local  management  of  hospitals,  and  would,  no  doubt, 
be  sanctioned  by  all  superintendents  and  aided  by  them, 
as  it  would  mitigate  their  responsibility.  Its  members 
and  agents  should  avoid  criticizing  hospital  manage- 
ment except  to  the  officials  interested.  The  order  should 
be  animated  by  that  philosophy  which  inspires  efforts 
through  presenting  patterns  of  excellence  in  nursing  the 
insane.  Possibly  hospital  managers  would  gladly  pro- 
mote the  work  by  establishing  a  Hberal  scale  of  wages 
depending  upon  the  rank  attained  by  the  employee.     Of 


132  CARE  OF  THE  INSANE 

course,  all  members  should  hold  and  wear,  when  on 
duty,  badges  representing  the  grade  to  which  they  had 
advanced. 

This  IS  a  most  worthy  object,  as  it  is  calculated  to 
benefit  two  greatly  neglected  classes  of  human  beings 
which  will  never  diminish  in  number, — the  insane  and 
their  custodians.  The  insane  have  an  acknowledged 
claim  upon  our  sympathies,  while  the  daily  but  unher- 
alded acts  of  genuine  heroism  displayed  by  true  nurses 
in  hospitals  for  the  insane  deserve  some  official  recogni- 
tion, and  must  receive  it  if  the  examples  of  such  devotion 
are  to  be  imitated  in  sufficient  numbers  to  cover  the 
field  of  necessity. 


APPENDIX. 

After  the  main  section  of  this  book  was  written 
friendly  critics  ^advised  the  introduction  of  concrete 
illustrations  —  a  description  of  actual  cases  —  which 
would  supply  clues  to  the  methods  by  which  the  rules 
and  suggestions  advanced  might  be  applied.  The  fol- 
lowing account  is  deemed  too  long  for^^  insertion  in  the 
theoretical  text.  One  or  two  episodes  in  the  experi- 
ence of  a  patient  will  serve  to  illustrate  how  force  and 
mechanical  restraint  can  be  avoided  in  managing 
patients,  especially  manic  cases  where  exhilaration  of 
spirits  is  associated  with  flighty  and  expansive  ideas. 

The  case  of  a  man  in  middle  life  suffering  from  attacks 
of  recurrent  maniacal  excitement  may  be  dted.  This 
patient  had  passed  through  several  previous  attacks, 
each  characterized  by  such  restlessness,  abnormal  de- 
grees of  self-assertion  and  unreasonable  conduct  that 
hospital  restrictions  had  been  necessary. 

Each  time  he  had  been  committed  to  the  same  hos- 
pital, where  he  had  established  a  reputation  for  cimning, 
incorrigibility  and  destructive  capacity.  With  insignifi- 
cant instnmaents  he  had  accompHshed  surprising  results 
through  shrewd,  persistent  efforts.  For  nights  and  days 
in  succession  he  seemed  to  require  no  sleep,  and  re- 

133 


134  CARE  OF  THE  INSANE 

peatedly  destroyed  clothing,  furniture  and  fixtures.  Al- 
ways intent  upon  escape  from  the  hospital,  ever  ready 
with  plausible,  ingenious  explanations  for  his  conduct 
when  interviewed  by  officials,  and  remarkably  skillful  in 
distorting  facts  to  impeach  his  attendants,  he  became 
the  object  of  their  dread  and  hatred.  He  never  lost  his 
temper,  usually  joked  and  laughed  when  restrained  by 
strait-jackets,  and  was  reported  to  have  once  remarked, 
when  able  to  catch  his  breath  while  being  subjected 
to  the  "water-cure  treatment,"  "Boys,  you  are  on  the 
right  track.  The  devil  is  in  me  and  you  may  drown 
him  if  you  keep  on."  When  subjected  to  such  rigid 
measures  he  often  expressed  satisfaction,  saying  his  was 
a  detective's  mission  and  he  was  anxious  to  experience 
the  worst,  as  he  contemplated  publishing  a  book  expos- 
ing insane  hospital  barbarities. 

The  care  of  this  patient  was  a  burden  to  the  manage- 
ment, and  in  time  arrangements  for  his  transfer  to  a 
similar  institution  in  another  state  were  perfected.  A 
junior  assistant  physician  who  at  an  earlier  period  had 
for  a  time  held  some  official  relations  with  the  patient 
volunteered  to  conduct  the  transfer.  The  patient,  by 
his  mental  alertness^  endless  schemes  and  good-natured 
acceptance  of  the  inevitable,  had  interested  this  young 
physician,  who  had  experienced  no  difficulty  in  manag- 
ing him.  Through  a  change  in  the  service,  about  three 
months  prior  to  the  date  of  transfer,  an  older,  more  ex- 
perienced hospital  physician  had  assumed  entire  charge 
of  the  ward  in  which  this  patient  was  located.  Owing 
to  the  progress  of  the  disease,  or  some  other  cause,  the 


CARE  OF  THE  INSANE  135 

patient's  worst  propensities  developed  and  trouble  with 
him  was  of  almost  daily  occurrence.  The  night  before 
the  transfer  he  planned  a  campaign,  probably  an  escape, 
and  opened  it  by  barricading  the  door  of  his  room. 
When  this  fact  was  discovered  by  the  night  watch  he 
considered  the  situation  sufficiently  grave  to  notify  the 
physician  in  charge.  The  doctor's  apprehensions  re- 
garding this  patient  were  such  that  he  hastened  to  the 
ward  and  personally  directed  efforts  to  dislodge  the 
maniac.  After  various  milder  measures  had  proved 
futile,  at  two  o'clock  in  the  morning  the  doctor  pro- 
cured a  crowbar  and  demolished  the  heavy  door.  The 
following  morning  at  nine  o'clock  the  junior  physician 
and  the  patient  set  out  for  the  other  hospital,  160  miles 
distant.  The  doctor  in  charge  of  the  hospital  they  left 
offered  to  send  any  desired  number  of  strong  attendants 
along  to  insure  custody  of  the  patient.  When  this  offer 
was  declined  he  urged  the  employment  of  one  or  more 
city  policemen.  When  that  proposition  was  rejected 
and  he  realized  that  no  semblance  of  force  was  to  be 
employed  in  the  transfer,  he  predicted  disaster  to  the 
enterprise.  This  recognized  authority,  who  as  medical 
chief  had  previously  managed  one  of  New  England's 
most  prominent  hospitals  for  the  insane  during  a  period 
of  two  years,  remarked,  ''It  cannot  be  done;  you  will 
never  get  the  patient  into  that  hospital  without  help." 

The  patient  had  in  some  measure  been  prepared  for 
this  trip.  With  this  object  in  view,  the  junior  assistant 
had  visited  his  ward  several  times,  had  expressed  re- 
grets that  the  patient  had  become  involved  in  so  much 


136  CARE  OF  THE  INSANE 

friction  with  employees  and  officers,  and  in  low,  confi- 
dential tones  had  predicted  that  a  time  would  come 
when  they  two  could  leave  the  hospital  together.  When 
they  were  finally  outside  the  institution  the  physician 
raised  the  question  of  their  destination.  The  patient's 
sense  of  gratitude  upon  finding  himself  so  free  no  doubt 
prompted  the  response  that  he  would  be  wholly  guided 
by  his  companion's  judgment.  Whereupon  the  latter 
suggested  a  trip  to  a  distant  city,  where  in  the  suburbs 
was  located  the  hospital  that  had  engaged  to  receive 
and  care  for  the  insane  man.  By  good  fortune  it  hap- 
pened to  be  election  day  in  the  city  which  was  their 
destination.  The  patient's  well-known  weakness  for 
detective  honors  supplied  a  key  to  the  doctor's  scheme 
of  procedure  and  a  text  for  earnest  discussion  the  live- 
long day.  The  glittering  rewards  for  that  detective 
skill  which  could  expose  crooked  political  ways  were 
considered  and  reconsidered.  As  they  journeyed  along, 
newspapers  were  purchased  at  every  opportunity  and 
their  columns  were  eagerly  scanned  to  discover  predic- 
tions of  fraudulent  voting  and  suggestions  of  bribery. 
By  such  devices  the  patient's  attention  was  kept  fully 
engrossed.  They  finished  their  day's  railroad  trip  early 
in  the  evening.  All  voting  places  were  closed,  but 
crowds  of  expectant  men  were  gathered  before  public 
bulletin  boards  and  in  hotel  offices.  After  mingling 
with  several  small  groups  in  succession,  they  sought  a 
pubhc  house  for  supper.  Later  they  started  out  again 
and  without  arousing  the  patient's  suspicion  the  doctor 
gradually  led  the  way  to  the  outskirts  of  the  city  and 


CARE  OF  THE  INSANE  137 

finally  discovered  the  entrance  to  the  hospital.  He 
assumed  much  surprise  upon  finding  himself  so  near  the 
good  doctor  who  superintended  the  institution  and  im- 
mediately resolved  to  call  upon  him  and  invited  the 
patient  to  go  along  as  his  friend,  assuring  him  that  they 
would  receive  a  cordial  welcome  for  the  night  in  virtue 
of  his  official  connection  with  an  institution  of  the  same 
class. 

The  patient  balked.  He  refused  to  go  into  the  hos- 
pital, but  stood  and  listened  to  the  doctor's  exhorta- 
tions, which  pointed  out  the  folly  of  neglecting  such 
an  opportunity  to  exercise  his  detective  ability,  such  a 
chance  to  peer  into  hospital  secrets,  and  extolled  their 
good  fortune  in  stumbhng  into  another  promising  field 
for  investigation  just  when  they  had  completely  failed 
to  make  good  in  connection  with  poKtical  games.  Then 
the  patient's  long-cherished  project  of  exposing  hospital 
abuses  was  recalled,  and  the  importance  of  gaining  a 
wide  and  varied  experience  before  attempting  to  formu- 
late general  conclusions  was  emphatically  dwelt  upon. 
The  idea  that  his  version  of  hospital  management,  or 
mismanagement,  would  attract  more  than  local  interest 
if  his  published  observations  were  Hmited  to  a  single 
institution  was  derided.  It  was  admitted  that  he  as- 
sumed some  risk  in  entering,  but  to  conceal  his  identity 
and  limit  the  hazard  of  being  detained  as  a  patient 
a  slight  change  in  his  name  was  suggested.  His  fam- 
ily name  chanced  to  be  a  compound  word,  and  he  was 
advised  to  use  the  initial  instead  of  the  first  two  syl- 
lables and  adopt  the  last  word  as  his  surname.     For  a 


138  CARE  OF  THE  INSANE 

long  time  they  stood  before  the  administration  building 
while  such  suggestions  were  hurled  at  him  and  his  ob- 
jections were  discussed.  Apparently  nothing  the  doctor 
said  influenced  him.  He  seemed  determined  to  go  no 
farther.  Finally  he  said,  ^'You  go  in  and  spend  the 
night  with  the  superintendent.  I'll  go  back  to  the 
city  and  meet  you  in  the  morning."  The  doctor,  with 
a  suggestive  inflection,  answered,  "Yes,  if  you  are  able 
to  find  me  to-morrow,"  and  turning  about  deliberately 
walked  towards  the  hospital. 

Before  taking  the  train  at  the  railroad  station  in  the 
morning,  the  doctor  had  purposely  slipped  out  of  the 
patient's  sight  for  a  short  time  apparently  wholly  in- 
different regarding  further  companionship  with  him. 
This  movement  early  disarmed  any  lurking  suspicion  the 
patient  may  have  entertained,  and  through  the  whole 
day  up  to  this  time  he  had  simply  dogged  the  doctor's 
footsteps. 

And  now  at  this  critical  juncture  was  a  similar  ruse 
going  to  be  effectual?  There  was  great  uncertainty, 
and  the  doctor  was  seriously  anxious  for  a  time  as  he 
advanced  along  the  walk  without  hesitation  or  back- 
ward glances.  By  the  time  he  had  covered  fifty  feet 
the  mental  strain  relaxed,  as  he  distinctly  heard  the 
patient's  peculiar  step  approaching  in  his  rear.  The 
patient  had  a  round  bald  head  with  a  full  face,  a  large- 
sized  body,  very  muscular  and  well  knit;  but  his  legs 
were  abnormally  short,  much  bowed  and  of  unequal 
length,  consequently  his  footfalls  always  resounded  like 
an  irregular  tattoo,  so  unusual  that  once  heard  they 


CARE  OF  THE  INSANE  139 

could  never  be  forgotten.  The  distance  between  them 
gradually  lessened  and  practically  closed  as  they  en- 
tered the  institution  reception  room,  where  a  supervisor 
was  in  waiting,  and  addressed  the  doctor  by  name. 
The  doctor  immediately  introduced  the  patient  as  his 
friend  and  requested  he  be  shown  a  quiet  room  at  once, 
explaining  his  seeming  haste  on  the  ground  that  they 
had  passed  a  fatiguing  day  and  that  his  friend  had  been 
unable  to  sleep  the  previous  night.  "What  is  the  pa- 
tient's name?"  asked  the  supervisor.  Immediately  he 
shifted  the  weight  of  his  body  from  the  short  leg,  his 
usual  pose,  to  the  longer  limb,  thus  presenting  a  bolder 
attitude,  and  elevating  his  chin  to  better  typify  his 
sense  of  self-importance  he  gravely  enunciated  the  abbre- 
viated name  so  recently  devised.  With  a  simple  good 
night  they  separated  and,  so  far  as  the  physician  antici- 
pated, never  to  meet  again.  Naturally  the  physician 
was  gratified  with  the  success  of  his  stratagem;  many 
of  his  projects  having  been  adopted  suddenly  to  meet 
unexpected  conditions  or  to  gain  advantage  by  follow- 
ing chance  suggestions,  he  never  suffered  any  conscien- 
tious scruples  concerning  the  ethics  of  his  conduct, 
although  admitting  that  as  a  rule  employing  decep- 
tion in  committing  the  insane  to  hospitals  cannot  be 
approved. 

The  circumstances  surrounding  this  case  were  so  un- 
usual the  methods  employed  seemed  justifiable.  The 
patient  was  not  being  removed  from  his  own  home  — 
from  kindred  or  trusted  friends.  He  was  leaving  an 
institution  where  his  presence  was  deplored  and  some 


I40  CARE  OF  THE  INSANE 

of  his  experience  had  been  bitter.  He  was  placed  in 
a  hospital  famed  for  the  consideration  shown  its  pa- 
tients, and  introduced  to  new  associations  where  preju- 
dice against  him  was  non-existent.  He  was  fully  in- 
formed respecting  the  character  of  the  institution  which 
he  voluntarily  entered,  and  he  was  not  misinformed  re- 
specting his  ability  or  inability  to  extricate  himself. 
He  was  misled  in  some  respects,  but  he  was  not  the  vic- 
tim of  naked  falsehoods.  When  alternative  measures 
are  considered,  the  mercy  of  the  successful  plan  is  obvi- 
ous. Had  this  transfer  been  conducted  by  policemen, 
he  would  have  been  exposed  as  a  culprit  to  crowds  of 
people  along  the  way  and  probably  would  have  been 
unnecessarily  stigmatized  by  wearing  handcuffs.  Had 
hospital  attendants  been  utilized  as  guards,  he  would 
have  suffered  constant  irritation,  would  have  attempted 
escape  or  would  have  offered  resistance,  and  few  men 
were  his  equal  as  regards  physical  strength  or  power  of 
endurance. 

Perhaps  it  would  be  more  interesting,  if  less  impor- 
tant, l-^  learn  how  the  patient  regarded  the  doctor's 
proffered  friendship.  Did  he  treat  the  affair  as  a  joke, 
or  did  he  revolt,  nurse  his  wrath  and  resolve  to  be  re- 
venged should  opportunity  offer?  The  sequel  will  suffi- 
ciently answer  such  questions,  for,  curiously  enough, 
they  subsequently  met  and  resumed  the  masquerade. 

While  on  a  vacation  trip  two  or  three  years  later  the 
assistant  physician  spent  a  few  days  in  New  York  City. 
The  then  new  post-office  building,  architecturally  con- 
spicuous in  City  Hall  Park,  attracted  his  attention  on 


CARE  OF  THE  INSANE  141 

one  occasion.  Having  ample  time  to  indulge  his  fancy, 
he  entered  and  sauntered  through  its  spacious  corridors 
admiring  their  massive  elegance.  He  thus  inspected 
several  stories  in  succession.  Ascending  the  broad  stair- 
case to  the  upper  floor,  he  casually  glanced  upward  and 
beheld,  to  his  great  surprise,  standing  calmly  on  the 
edge  of  the  landing,  his  old  patient  and  companion  for  a 
memorable  day's  travel,  whom  he  had  neither  seen  nor 
heard  from  after  the  hospital  door  had  closed  shut  be- 
tween them.  With  an  exclamation  of  surprise  and  great 
interest  he  advanced  to  complete  the  usual  form  of 
greeting,  but  his  quondam  partner  in  simulation  held 
himself  in  reserve.  With  a  mien  of  the  traditional 
North  American  Indian  he  dehberated  for  a  time,  and 
then  drawled  out,  '^I  don't  know  about  you.  I  am  in 
no  haste  to  resume  acquaintance  with  a  man  who  played 
me  such  a  trick  as  you  did."  The  doctor  expressed  re- 
gret that  their  past  relations  were  susceptible  of  such 
opposite  interpretations  as  his  own  views  and  those  held 
by  the  patient.  He  begged  a  reconsideration  of  the 
whole  affair  and  gradually  compelled  the  patient  to  ad- 
mit the  transfer  had  been  made  imperative  by  other 
parties  —  that  those  responsible  for  the  change  would 
have  planned  the  trip  without  the  slightest  considera- 
tion of  the  patient's  comfort  or  feelings  and  would  have 
publicly  subjected  him  to  humiliation  by  a  conspicu- 
ous exhibition  of  poHce  or  hospital  authority.  He  also 
acknowledged  he  was  much  more  kindly  treated  at  the 
latter  hospital  and  ought  not  to  treasure  up  resentment 
against  one  who  voluntarily  and  without  personal  profit 


142  CARE  OF  THE  INSANE 

had  actually  saved  him  much  annoyance,  possibly  physi- 
cal suffering,  and  had  favorably  changed  the  drift  of  his 
experience. 

When  this  debatable  point  in  their  previous  alhance 
had  been  thoroughly  exploited,  the  doctor  asked  when 
and  how  he  had  left  that  northern  hospital,  how  he 
happened  to  be  in  New  York  City,  and  what  he  pro- 
posed to  do.  Answers  to  a  few  such  questions  enabled 
the  doctor  to  fully  comprehend  the  situation.  The  pa- 
tient had  been  well  treated  at  the  last  hospital,  but  one 
night,  after  about  six  months'  residence,  he  had  quietly 
sUpped  out  of  the  building,  determined  to  walk  home. 
It  being  the  autumn  season,  he  readily  found  employ- 
ment with  farmers  along  the  route,  working  a  few  days 
in  each  of  several  places,  and  finally  reached  home  in 
good  condition  with  surplus  cash  in  his  possession.  His 
mental  condition  had  changed  with  time,  and  when  he 
met  his  relatives  he  presented  the  subacute  reactionary 
stage  of  his  mental  cycles,  and  being  a  bachelor  he  was 
welcomed  by  his  brother  who  lived  at  the  old  home- 
stead. He  had  remained  there  more  than  two  years, 
quiet  and  agreeable  to  all.  He  had  undoubtedly  made 
himself  useful  about  the  house  and  in  the  garden.  But 
now  his  periodical  mental  ebullition  was  in  evidence,  re- 
flecting his  emotional  intoxication.  His  proHfic  fancy, 
disregarding  logical  bounds,  involved  him  in  chimerical 
schemes.  Again  he  was  in  his  own  imagination  a  mas- 
ter detective.  He  declared  he  was  a  secret-service  man 
in  the  employ  of  the  United  States  government.  He  as- 
serted that  serious  affairs  on  the  Pacific  Coast  required 


CARE  OF  THE  INSANE  143 

his  immediate  attention  and  presence,  and  that  he  must 
start  for  California  not  later  than  the  following  morn- 
ing. He  had  been  disappointed  in  trying  to  find  the 
office  of  the  government  transportation  agent,  although 
a  gentleman  in  the  street  had  directed  him  to  the  upper 
floor  of  the  post-office  building.  Thus  came  about  this 
accidental  meeting  which  neither  party  anticipated  or 
desired. 

As  the  history  of  mental  disorder,  such  as  was  repre- 
sented by  the  patient,  concerning  both  the  delusions 
entertained  and  the  personal  conduct,  repeats  itself,  the 
doctor  instantly  realized  that  the  patient  had  relapsed, 
had  surreptitiously  left  home,  and  that  his  relatives 
must  be  anxious  regarding  his  whereabouts  and  his 
welfare,  and  that  measures  to  protect  him  ought  to  be 
promptly  instituted.  The  doctor's  recollection  of  the 
patient's  history  embraced  the  fact  that  a  nephew  was 
a  New  York  City  business  man,  and  a  call  upon  him  was 
proposed.  The  patient  emphatically  refused  to  have 
anything  to  do  with  his  relatives.  But  at  length  he  so 
far  yielded  to  continued  persuasion  that  he  named  the 
street  and  number  but  seemed  most  unwilling  to  ven- 
ture there.  Yet  an  hour's  pleading  did  prevail,  and 
eventually  he  led  the  way,  only  a  short  walk,  to  the 
office  of  his  only  brother's  son. 

The  young  man  was  agreeably  surprised  to  see  his 
uncle  enter  his  presence,  but  for  a  time  he  regarded  the 
doctor  with  suspicion,  not  readily  accepting  the  ex- 
planation of  attending  circumstances;  being  unable  to 
comprehend  why  a  stranger  to  him  should  from  disin- 


144  CARE  OF  THE  INSANE 

terested  motives  come  there  with  this  man  whose  ner- 
vous manner  and  flighty  conversation  stamped  him  as 
decidedly  pecuKar.  Soon  he  ushered  his  uncle  into  a 
private  room,  and,  leaving  him  there  after  a  long  con- 
versation, he  interviewed  the  doctor.  After  repeated 
conferences  of  that  order,  and  finding  that  each  visitor 
confirmed  the  other's  statements,  and  that  his  own  fam- 
ily history  was  well  known  by  the  doctor,  he  accepted 
in  good  faith  the  claim  that  the  doctor,  knowing  the 
patient,  appreciated  the  condition  in  which  he  found 
him  and  simply  wished  to  deliver  him  to  his  relatives. 
The  young  man  then  expressed  his  appreciation  for  the 
service  rendered  and  drew  from  his  pocket  a  telegram 
which  read  as  follows,  viz. :  *' Reuben  has  gone  on  another 
tear;  he  ran  away  from  home.  Will  probably  go  to 
New  York.  If  he  turns  up  there  have  him  arrested  and 
confined  on  the  Island  imtil  I  can  arrange  his  commit- 
ment to  the  Retreat." 

The  message  was  from  his  father,  who  was  a  physi- 
cian, and  the  son  proposed  to  act  upon  it  literally,  and 
at  once,  by  handing  his  uncle  over  to  the  city  police. 
Such  an  unpleasant  termination  to  a  call  which  was 
the  result  of  his  solicitation  had  not  been  anticipated 
by  the  doctor,  and  he  strenuously  objected  to  the  plan. 
Then  followed  a  long  discussion  upon  future  manage- 
ment of  the  patient.  Various  expedients  were  sug- 
gested, but  all  met  with  objections.  The  nephew  would 
not  go  with  his  uncle.  He  felt  he  could  not  leave  his 
business,  and  admitted  he  lacked  the  necessary  courage 
to  undertake  even  temporary  management  of  the  case. 


CARE  OF  THE  INSANE  145 

In  time  the  patient  was  admitted  to  the  conference. 
The  doctor  plainly  told  him  their  convictions  that  he 
ought  to  go  to  the  hospital  for  care  and  treatment.  Of 
course  he  protested  at  first,  but  his  opposition  to  the 
plan  faded  as  the  doctor  pointed  out  the  improbability 
of  his  success  as  a  poKtical  detective  and  assured  him 
that  his  earlier  conception  to  reform  insane  hospitals 
was  a  much  more  promising  proposition ;  that  much  of 
hospital  life  and  methods  remained  unknown  to  him; 
that  he  ought  to  witness  how  a  change  in  hospital  man- 
agement could  alter  ward  conditions  and  note  how 
changed  the  life  of  patients  became  when  the  old  coer- 
cive practice  was  no  longer  the  rule;  that  he  ought  to 
revisit  his  old  hospital  haunts  and  compare  present  con- 
ditions with  such  as  he  had  formerly  encountered  there; 
that,  with  the  exception  of  the  informant,  every  ofhcer 
in  the  hospital  as  he  knew  it  had  gone  and  new  men 
now  filled  the  positions.  The  patient  became  so  much 
interested  in  this  suggestion  that  he  offered  to  return 
with  the  doctor.  The  doctor  regretted  he  could  not 
cut  short  his  vacation  to  accommodate  his  old  friend, 
whereupon  the  patient  complacently  announced  that  it 
would  be  entirely  agreeable  to  him  to  remain  in  New 
York  until  the  physician's  vacation  expired.  This  con- 
cession on  his  part  could  not  be  favorably  entertained. 
While  puzzHng  over  the  difficulties  to  be  met,  the  doctor 
had  an  inspiration  and  taking  the  patient  aside  suggested 
he  go  alone  to  the  hospital.  The  boldness  of  this  pro- 
posal strongly  appealed  to  his  imagination.  The  doctor 
elaborated  the  proposition.    He  proposed  giving  a  let- 


146  CARE  OF  THE  INSANE 

ter  of  introduction  to  the  new  superintendent,  asking 
him  to  receive  the  assistant's  old  friend  and  former 
patient  and  treat  him  like  a  guest  until  the  assistant's 
return.  He  finally  confided  to  the  patient  the  contents 
of  the  telegram  he  had  just  read,  showing  that  the 
brother  and  nephew  would  insist  upon  his  commitment, 
and  that  the  police  would  be  requested  to  arrest  him  if 
he  left  their  presence;  that,  once  in  the  hands  of  the 
poHce,  there  would  follow  court  proceedings,  temporary 
jail  residence  and  ultimately  a  journey  to  the  hospital 
under  the  espionage  of  rough  policemen.  Why  not  with 
this  warning  and  such  an  opportunity  give  his  family 
the  surprise  of  their  lives  —  why  not  checkmate  them  in 
the  game  they  were  playing!  The  audacity  involved 
in  executing  such  a  counter  move  was  too  captivating 
for  him  in  his  peculiar  state  of  mind  to  resist,  and  he 
eagerly  responded,  ^'I'U  do  it." 

The  nephew  was  then  informed  that  all  difficulties 
had  been  solved  and  the  terms  of  the  capitulation  were 
imparted  to  him.  He  regarded  the  arrangement  as 
decidedly  visionary  and  refused  his  sanction.  The  doc- 
tor defended  the  plan  and  assured  the  nephew  that  the 
patient,  having  given  his  word  of  honor,  could  be  de- 
pended upon  to  fulfill  his  agreement.  To  be  upheld  as 
a  man  of  honor  before  his  doubting  relative  and  by  the 
assistant  physician  of  an  institution  where  as  he  knew 
his  name  had  usually  been  regarded  as  synonymous 
with  perfidy,  flattered  his  vanity,  of  which  he  always 
retained  a  good  measure,  especially  when  in  his  elated 
moods,  and  he  became  eager  to  substantiate  the  doctor's 


CARE  OF  THE  INSANE^'  147 

prediction  concerning  his  reliability.  ^'Will  you  hon- 
estly do  it?"  asked  the  nephew.  ''Yes,"  responded  the 
patient.  "The  doctor  hoaxed  me  once,  but  no  matter, 
I'll  go  anywhere  he  says,  if  it  is  to  h — 1." 

Misgivings  still  lingered  in  the  nephew's  mind.  As 
he  started  with  his  uncle  for  the  42nd  Street  Station, 
turning  aside  he  remarked  to  the  doctor,  ''What  will 
father  think  of  me  if  uncle  breaks  his  promise?  Now 
we  have  him  in  our  power,  it  doesn't  seem  sensible  to 
trust  him  alone."  Nevertheless  he  duly  performed  his 
assigned  part.  He  saw  his  uncle  off  in  the  train  for 
Hartford  with  a  through  ticket  in  his  hand.  Messages 
and  letters  were  dispatched  to  the  hospital  authorities 
announcing  the  coming  of  the  patient  and  requesting 
his  safe  custody  until  relatives  could  perfect  arrange- 
ments for  his  continued  treatment.  This  "irrespon- 
sible" man  kept  his  agreement  in  every  particular. 
When  he  left  the  train  he  entered  a  public  carriage  and 
ordered  the  driver  to  convey  him  to  the  Retreat.  Upon 
reaching  the  institution  he  hurried  into  the  business 
office  and  requested  the  clerk  to  pay  the  hackman  and 
charge  the  amoimt  to  him.  He  then  presented  his  letter 
of  introduction  to  the  new  superintendent  and  was 
assigned  a  room  in  the  patients'  department,  where  the 
assistant  found  him  on  his  return. 

For  several  years  he  remained  at  the  hospital  as  a 
patient,  but  never  afterwards  did  he  attempt  to  escape. 
Nor  did  he  become  involved  in  serious  difficulties  with 
employees  or  officers.  His  relations  with  the  doctor 
who  induced  him  to  return  to  the  hospital  from  which 


148  CARE  OF  THE  INSANE 

his  former  deliverance  had  seemed  to  him  like  a  tri- 
umph in  the  thick  of  calamities  continued  most  cordial 
to  the  end.  The  revolution  in  his  hospital  conduct 
may  be  largely  credited  to  the  consideration  he  received 
and  the  freedom  he  enjoyed  during  this  his  last  sojourn 
there.  Instead  of  being  constantly  regarded  with  the 
irritating  suspicion  of  tactless  keepers,  as  in  former 
days,  he  escaped  such  thralldom  by  having  parole  of  the 
premises,  or  the  city,  the  greater  portion  of  the  time. 
Whereas  in  previous  attacks  he  had  been  confined  to 
narrow  quarters  as  a  rule,  being  frequently  locked  in  a 
strong  room  to  expiate  past  misdeeds,  or  to  forestall  his 
aggravating  pranks,  which,  it  must  be  confessed,  some- 
times degenerated  to  the  level  of  malicious  mischief,  he 
was  now  at  liberty  to  work  off  his  abnormal  energy  in 
walking  about  the  country.  Instead  of  restrictions  in 
numberless  ways  which  had  been  his  former  lot,  he  was 
permitted  to  busy  himself  in  the  garden,  and  for  a  time 
he  canvassed  the  city  for  the  sale  of  some  book  or 
kitchen  device.  Hence  he  came  to  look  upon  the  hos- 
pital as  less  a  prison  and  more  his  hotel. 


CARD    INDEX 


In  hospitals  for  the  insane  the  card  index  is  no  doubt 
generally  utilized  for  convenience  of  reference  in  ordinary 
business  matters.  But  comparatively  few  institutions, 
it  is  believed,  keep  a  card  index  of  all  important  facts  to 
be  found  in  the  case  records. 

Unless  such  records,  already  voluminous  in  some  hos- 
pitals, are  made  available  through  a  classified  card-index 
system,  the  vast  amount  of  high-class  professional  work 
being  done  and  recorded  in  the  leading  institutions,  can- 
not be  utihzed  for  scientific  papers  and  generalization; 
ends  too  important  to  be  ignored. 

If  the  task  of  indexing  back  records  seems  too  formi- 
dable to  be  undertaken,  certainly  current  records  should 
be  so  kept  that  all  essential  points  could  be  easily  noted 
in  a  card  index. 

By  providing  for  each  case  an  index  sheet  bearing  a 
printed  list  of  all  important  symptoms  of  nervous  and 
mental  diseases  as  well  as  a  classification  of  insanity  and 
vital  facts  incident  to  personal  histories,  the  assistant 
physician  can  easily  check  the  appropriate  terms  in  such 


149 


150  CARE  OF  THE  INSANE 

an  index  as  the  history  and  hospital  development  of 
patients  become  familiar. 

The  checked  index  on  the  individual  sheets  can  at 
convenient  intervals  be  transferred  to  a  card-index  sys- 
tem by  office  clerks. 

Blank  space  on  the  case-index  sheet  should  be  provided 
upon  which  may  be  written  features  special  to  any  one 
case  as  may  be  required.  When  individual  case  port- 
folios are  provided  for  all  patients  the  index  sheet  is  filed 
with  the  other  papers,  therefore  it  is  advisable  to  use 
colored  paper  for  such  sheets  so  identification  may  cause 
no  delay. 

When  a  superintendent  attempts  to  keep  control  of 
hospital  discipline,  the  card  system  would  seem  to  be 
a  necessity.  Otherwise  many  minor  troubles  entirely 
escape  his  attention;  a  condition  which  should  not  be  al- 
lowed if  the  more  serious  affairs  are  to  be  avoided.  For 
the  purpose  of  keeping  posted  upon  ward  friction,  cards 
should  be  kept  in  every  ward  for  use  in  reporting  all 
instances  of  trouble  with  a  patient.  The  employees 
should  understand  that  they  must  fill  out  a  card  promptly 
under  conditions  stated  on  the  card,  viz. :  when  a  patient 
escapes,  attempts  to  escape,  receives  an  injury,  by  acci- 
dent or  otherwise,  has  to  be  handled  with  force,  or  is 
secluded.  The  card  should  then  be  given  at  once  to  the 
assistant  physician  for  his  signature  and  he  should  turn 


CARE  OF  THE  INSANE  1 51 

it  over  to  the  superintendent.  At  his  early  convenience 
the  superintendent  can  take  the  card  to  the  ward  and 
institute  a  private  investigation  sufficiently  thorough  to 
satisfy  himself  as  to  the  responsibility  of  the  several 
parties. 

He  can  then  make  his  decisions  and  write  comments 
on  the  back  of  the  card  and  file  it  under  the  name  of 
the  patient.  If  complaints  of  the  treatment  of  patients 
are  made  to  him  in  his  office,  such  memoranda  at  hand 
will  afford  him  satisfaction  and  assure  the  complainant 
that  the  patient  is  not  being  neglected.  By  this  method 
a  superintendent  can  keep  himself  posted  upon  all  the 
bad  history  the  hospital  is  making  —  just  the  things 
most  essential  for  him  to  know. 

Besides  learning  at  once  if  the  attendant  has  shown 
the  right  spirit  in  the  incident  reported  and  demon- 
strated good  sense  in  managing  the  affair,  such  interviews 
as  must  follow  each  report  can  be  made  the  occasion  for 
a  private  lecture  to  the  employee  in  which  the  impor- 
tance of  managing  the  patient  with  skill  instead  of  through 
threats  and  force  can  be  enlarged  upon.  Even  when  the 
trouble  is  of  little  consequence,  the  employees  usually 
will  be  more  thoughtful  before  getting  involved  again, 
as  they  soon  dread  the  pointed  instruction  which  is  their 
due  under  such  circumstances. 

When  such  a  reporting  system  is  estabhshed,  neglect 


152  CARE  OF  THE  INSANE 

to  make  a  report  should  never  be  excused.  If  a  report 
is  withheld  by  the  nurse,  the  chances  are  that  some 
patient  will  remind  the  superintendent,  the  first  good 
opportunity,  that  something  occurred  which  should  have 
been  reported.  They  get  so  accustomed  to  his  investi- 
gations that  they  suspect  something  has  gone  wrong  if 
he  does  not  appear  soon  after  troubles  occur  to  quiz  the 
patient  and  attendant.  The  admonition,  telling  what 
to  report,  may  be  printed  in  small  type  across  one  end 
of  the  cards. 

If  a  superintendent  desires  to  aid  his  medical  staff  in 
acquiring  a  thorough  knowledge  of  psychiatry,  and 
make  the  study  interesting,  he  can  promote  that  object 
by  providing  and  maintaining  a  card  index  of  the  litera- 
ture of  insanity  as  found  in  standard  works  on  the  sub- 
ject, and  in  current  periodicals  in  English,  German  and 
French.  Where  the  daily  clinic  is  practiced,  and  where 
the  cases  are  carefully  analyzed,  such  an  index  will  enable 
the  whole  faculty  to  obtain  and  utilize  a  broad  knowledge 
of  insanity.  For  this  purpose  the  cards  should  not  be 
used  for  quotations  so  much  as  for  a  concise  typewritten 
statement  in  English  of  the  writer's  claim  or  argument, 
the  point  made,  or  the  fact  stated.  The  aim  should  be 
to  epitomize  without  losing  the  writer's  point  of  view  or 
misstating  his  conclusions.  Good  judgment  and  discre- 
tion must  be  exercised  to  avoid  putting  second-hand  and 


CARE  OF  THE  INSANE  153 

worthless  statements  on  the  cards.  Borrowed  ideas  and 
restatements,  of  no  scientific  or  controversial  worth, 
should  be  ignored. 

Single  cards  should  carry  single  ideas  only.  When 
authors  bring  together  different  subjects  or  different 
phases  of  one  subject,  the  several  items  should  each 
have  its  card  to  be  filed  in  its  appropriate  place. 
Otherwise,  one  searching  for  information  on  a  given 
point  might  be  unable  to  find  the  correct  card.  When 
the  information  to  be  indexed  is  of  uncertain  bearing 
or  of  doubtful  apphcation,  duphcate  cards  can  be  made, 
each  filed  in  separate  sections  under  the  right  guide 
card. 

In  order  to  file  cards  so  that  each  one  is  quickly  avail- 
able as  occasion  may  desire,  a  comprehensive  scheme  for 
fifing  must  be  elaborated,  and  a  copy  kept  at  hand  to  aid 
in  phrasing  the  card  as  well  as  in  fifing  it.  In  the  card 
drawers  a  word  must  serve  as  a  guide,  and  this  word 
should  be  kept  in  mind  when  the  abridged  card  content 
is  dictated  or  written. 

The  subject  of  Insanity  should  be  divided  into  great 
divisions  such  as  historical,  etiology,  symptomatology, 
diagnosis,  prophylaxis,  pathology,  treatment,  medico 
legal,  etc.  Each  division  should  be  divided  into  sub- 
divisions, and  subdivisions  into  heads,  and  heads  into 
subheads,  so  the  guide  cards  will  embrace  all  conceivable 


154  CARE  OF  THE  INSANE 

points  upon  which  information  concerning  insanity  may 
be  foimd.  Under  the  several  major  divisions,  heads  and 
subheads  may  be  duplicated. 

Every  physician  can  keep  a  card  index  of  his  reading, 
and,  if  that  is  not  extensive,  a  simple  arrangement  of 
cards  may  answer.  But  hospitals  for  the  insane  ought 
to  have  a  complete  summary  of  the  literature  upon 
insanity,  and  in  order  to  make  it  thoroughly  practical  a 
very  complete  system  of  guide  cards  should  be  formu- 
lated in  advance.  A  form  should  be  printed  on  each 
card  to  assist  in  filing  and  in  sorting  if  accidentally  mixed. 
The  department  or  division  should  stand  out  conspicu- 
ously. The  author's  full  name  should  always  occupy 
the  same  position  on  the  card.  The  date  of  the  publi- 
cation, as  well  as  the  title  and  page,  should  be  clearly 
stated.  If  a  journal,  the  name,  year,  number  and  page 
should  be  given.  As  duplicate  cards  could  be  filled  in  at 
comparatively  little  additional  cost,  it  would  seem  advis- 
able for  the  several  hospitals  in  a  state,  or  from  a  wider 
district  even,  to  combine  in  the  preparation  of  such  an 
index.  There  is  nothing  chimerical  in  this  proposition  for 
a  broad  card  system  covering  the  whole  field  of  hterature 
on  insanity.  Indeed,  such  a  card  system  pertaining  to 
tuberculosis  has  been  devised  and  brought  down  to  date 
by  an  eminent  specialist,*  who  has  managed  a  private 
*  Dr.  Karl  von  Ruck,  Asheville,  N.  C. 


CARE  OF  THE   INSANE  155 

sanitorium  and  attended  to  much  outside  business  while 
perfecting  such  an  index,  which  now  has  about  13,000 
guide  cards. 

The  owner  has  either  signified  what  the  contents  of 
the  cards  should  be,  or,  when  assistants  have  been  en- 
gaged in  making  cards,  he  has  inspected  each  one  before 
it  was  filed. 


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